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Case presentation & literature review

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Two cases

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Dr. Saad Subahi Consultant cardiologist at ALRIBAT university hospital

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46 old male admitted electively to hospital on 12/05/2010 for lamincectomy

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MRI showed disc prolapse at L4&5 No significant P.H

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Next morning (13/05/2010) he had inter laminar discetomy, done under G.A. Uneventful course

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2 nd post-operative day, at 10:30 a.m (Friday) he was seen by the neurosurgeon Patient was comfortable, apart from minimal backache Vitals were stable He was advised to mobilize out of bed

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Immediately after mobilization patient developed sudden SOB; taken back to bed, noticed to be sweaty with cold extremities.

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Soon, prior to any intervention, respiratory and subsequently, cardiac arrest ensued

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Advanced cardiac life support was immediately implemented. After resumption of spontaneous circulation he was transferred to ICU

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Before connecting him to M.V. he had second arrest ; CPR (for 3 minutes) -----> Resumption of spontaneous circulation

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Given 2 liters of N/S because of B.P of 75/45, followed by dopamine infusion, titrated up to 20mcg/kg/min

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He was connected to M.V. at 11:0 a.m I attended the patient at 11.30 am

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Vital signs : pulse 145/min; B.P : 88/52; oxygen sat 99% There was prominent jugular venous distention.

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The lungs were clear on auscultation, with normal breath sounds

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12-lead ECG showed sinus tachycardia, S 1 Q 3 T 3 pattern & RBBB Chest x-ray : normal CBC, Urea & electrolytes were normal

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A presumptive diagnosis of massive pulmonary embolism was made.

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At 12:15 p.m seen by Dr. Saad & bed side ECHO done

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Dr Saad ECHO Daignosis Discussed with the neurosurgeon and started on streptokinase 1.5 million units, over one hour. Events during streptokinase infusion. Hypotension & bradycardia Severe biventricular dysfunction ------- adrenaline infusion Improvement in biventricular function, pulse rate & blood pressure D/C of adrenaline infusion Maintenance of normal B.P Recovery of RT ventricular function

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Diagnosis: Massive PE-induced cardiac arrest + right heart thrombi-in-transit

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At 1:30 pm was hemodynamically stable.

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ECHO, next morning (15 th ), at 8:15 am

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At 10:0 am : Improvement in BP & O2 saturation, & he was obeying commands

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Shifted to spontaneous mode : TV > 300ml, rate 25-28/min & oxygen saturation 100% on FIO2 0.40

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Accordingly he was extubated and connected to oxygen by simple mask (50%)

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ABG 30 min post extubation : PH : 7.35 PCO2 : 37 mmHg PO2 : 163 mmHg O2 sat : 99% HCO3 : 22 mmol/L BE : -3 mmol/L

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Time from clinical suspicion to thrombolytic therapy : one hour

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33 years female presented to the emergency room with 2 hours history of sudden shortness of breath 3/08/2011 at 10.0 am

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One week prior to presentation she had bilateral fracture of the tibial shaft (RTA), treated conservatively at home (long leg casting). Was completely confined to bed.

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On presentation to A&E Tachypnic : 40/min Pulse : 140/min. B/P : 70/35 Confused & restless Normal 1+11 heart sounds Chest : normal auscultation

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ECG : sinus tachycaria, inverted T- in V1-3 ABG (NRM) : PH : 7.29 PCO2 : 31 mmHg PO2 : 66 mmHg HC03 : 16 mmol/l

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Chest x-ray : normal

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High clinical suspicion of massive PE.

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ECHO : done by Dr Saad, within 15 min from time of presentation. 1 liter of N/S, followed by dopamine infusion

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ECHO.

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Started immediately on IV streptokinase 1.5 million units over one hour.

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ARRESTED : CPR was carried and streptokinase infusion was continued during CPR She was intubated and CPR continued for 12 min ------ > ROSC

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Transferred to ICU on dopamine infusion Connected to the ventilator

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Improvement of oxygenation, but continued to require inotropics

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On the same day she had 2 nd arrest at 9:30 pm. CPR for five minutes ------> ROSC

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Hospital course AKI required peritoneal dialysis Acute peritonitis Recovered with a polyuric phase, during which she developed massive hematuria.

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On day 5 : massive upper GIT bleeding required blood transfusion. On day 7 : blocked ETT.

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Day 11 on mechanical ventilation, she satisfied all extubation criteria. She was extubated and connected to oxygen by simple mask.

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After 29 days in ICU she was transferred to the ward, fully conscious and oriented with normal renal function; and discharged home 5 days later.

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Time from clinical suspicion to thrombolytic therapy : 20 min.

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Transthoracic ECHO was done at the bedside in critically ill patients Performed by the clinician who has complete knowledge of the patients current clinical status Immediately established the diagnosis and directed towards the appropriate intervention.

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POLICY STATEMENT Emergency Ultrasound Guidelines Approved October 2008

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Focused Cardiac Ultrasound in the Emergent Setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency Physicians J Am Soc Echocardiogr 2010;23:1225-30.

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Bedside Applications of Ultrasound Cleveland Clinic February 2013

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Introduction It was unimaginable 100 years ago to be able to draw a picture from sound.

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Similarly it was written in The Times in 1834: The medical profession was unlikely ever to start using the stethoscope because its beneficial application requires much time and gives a good bit of trouble.

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Ultrasound, which is our future stethoscope, has passed through the same story, as the medical community was initially reluctant to use it for diagnosing life-threatening conditions by nonradiologists.

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Early ultrasonography machines were bulky and their use was confined to imaging laboratories.

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Compact and portable ultrasound machines that provide excellent image quality

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Has resulted in profusion of bedside applications

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The concept of an ultrasound stethoscope is becoming a reality.

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Ultrasonography has been widely used in cardiology, radiology, obstetrics, and emergency medicine.

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More recently, its use has become more widespread in pulmonary and critical care medicine.

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Bedside Applications in Pulmonary and Critical Care Medicine Ultrasonography conducted at the bedside by a clinician, known as point-of-care ultrasonography, dates back more than twenty years, but has come to prominence in the last 5-7 years and is spreading quickly.

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Has 2 primary uses in pulmonary and critical care medicine:

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Procedural guidance Rapid bedside diagnosis in critically ill patients

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Ultrasound-guided procedures Some of the common ultrasound-guided procedures performed in the critical care unit include

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Establishing vascular access and monitoring catheters

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Pericardiocentesis

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Thoracentesis and pleural catheter placement

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Paracentesis

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Lumbar punctures

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Arthrocentesis

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Regional anesthesia

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Ultrasound guided crycothyrotomy and tracheostomy

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Confirmation of transvenous pacing wire placement

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Diagnostic applications of Point-of- care ultrasound In contrast, to formal ultrasound; is performed by the clinician who is currently caring for the patient and who has complete knowledge of the patients current clinical status.

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Interpretation of the ultrasound images and immediate clinical decisions are made by the clinician conducting the imaging study, thereby enabling rapid intervention and assessment.

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The dynamic nature of the techniques and ability to repeat an examination rapidly, as needed without waiting on an imaging specialist to perform the examination and interpret it, allows the individual intensivist to monitor patient progress and effects of therapeutic interventions.

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Advantages point-of-care ultrasound Fast Performed at the bedside Non-invasive Immediate results Repeatable Nonexpensive without the risk of radiation

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Point-of-care ultrasound Goal-Directed Echocardiography Lung Ultrasonography Goal-Directed Abdominal Ultrasonography Goal-Directed Vascular Ultrasonography

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Lung Ultrasonography International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med (2012) 38:577591

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Pleural effusion

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Pneumothorax

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Lung consolidation

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Interstitial syndrome Pulmonary edema of various causes Interstitial pneumonia or pneumonitis Diffuse parenchymal lung disease (pulmonary fibrosis)

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The four chest areas per side considered for complete eightzone lung ultrasound examination. These areas are used to evaluate for the presence of interstitial syndrome.

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Focused (goal-directed) echo Since its inception over 60 years ago, echocardiography has remained largely the province of the cardiologist, providing a tool to evaluate anatomical and physiological abnormalities of the heart.

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In recent years, the application of echocardiography has extended to the diagnosis and monitoring of the critically ill patients in the general intensive care unit --------------> Goal-directed Echo

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Transthoracic Echo, performed at the patients bedside and interpreted by the treating intensivist to answer specific clinical questions.

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The principal role for FOCUS is the time-sensitive assessment of the symptomatic patient.

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Clinical Indications for Focused Echo Hypotension/Shock Dyspnea/Shortness of Breath Chest pain Cardiac Trauma Cardiac Arrest

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Goals of the Focused echo in the Emergent Setting Assessment of global cardiac systolic function and contractility

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Assessment of the right ventricular function

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Assessment for the presence of pericardial effusion

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Intravascular Volume assessment

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Cardiac arrest Volume Assessment Chest pain

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Cardiac arrest Successful resuscitation requires potentially reversible causes to be diagnosed and reversed, and many of these can readily be diagnosed using echocardiography.

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Periresuscitation echocardiography provides the only realtime bedside diagnostic tool that can diagnose some of the potentially reversible causes of cardiac arrest and can be regarded as analogous to pulse oximetry or ECG monitoring.

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Focused echocardiography can be performed within the time frame allowed during the pulse check of the advanced life support (ALS) algorithm.

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A sub-xiphoid probe position has been recommended.

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The goal of the FOCUS in the setting of cardiac arrest is to improve the outcome of cardiopulmonary resuscitation by:

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Determining a cardiac etiology of the cardiac arrest :

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Tamponade Coronary artery disease Pulmonary embolism hypovolemia

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Identifying organized cardiac contractility to help the clinician distinguish between: -Asystole -Pulseless electrical activity (PEA) and -Pseudo-pulseless electrical activity,

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True PEA is defined as the clinical absence of ventricular contraction despite the presence of electrical activity.

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Whereas pseudo-PEA is defined as the presence of ventricular contractility visualized on cardiac ultrasound in a patient without palpable pulses.

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Therefore, making the diagnosis of pseudo- PEA can be of diagnostic and prognostic importance.

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If mechanical contractility without palpable pulse is identified (pseudo-PEA), the management can then focus on hypotension rather than asystolic type resuscitation pathways.

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Lastly Guiding life-saving procedures at the bedside such as pericardiocentesis, or evaluate the position of transvenous pacemaker placement.

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Volume Assessment In the critically ill, a number of parameters have been found to indicate severe hypovolaemia. These include :

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The presence of a small, hyperkinetic left ventricle (in the presence of a normal right ventricle) with end-systolic cavity obliteration.

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A left ventricular end-diastolic area of less than 5.5 cm2/m2 body surface area.

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A small inferior vena cava (diameter