Ultrasound in Shock & Peri-Arrest

Dr Bill Coode

Consultant in Emergency Medicine

• Discuss role of ‘shock scan’

• Focused Echo

• IVC assessment

• ‘Shock Scan’ protocol

• Clinical Cases

Why Ultrasound In Shock?

• Initially clinical diagnosis of shock etiology correct in only 50% patients

» Jones, A. CCM 2004;32(8):1703

Common Causes Of Shock

LVF Tension PTX Haemoperitoneum Hypovolemia

Tamponade PE Valvular Leaking AAA

Adrenal failure ThyrotoxicosisAortic

dissectionAnaphylaxis

Neurogenic

shockToxic ACS Arrhythmia

GI Bleed SepsisMesenteric

IschaemiaMetabolic

‘Shock Scan’

• FATE scan• Focus Assessed Transthoracic Echo

• ACES scan• Abdominal and Cardiac Evaluation with

sonography in Shock

Scanning Technique

FAST

AAA

PTX

HTX

Focused Echo

IVC assessment

ED U/S IN SHOCK

.

OCCULT BLEEDING

CI > 0.5

TACHY/HYPERKINESIS

TACHY/HYPERKINESISCI > 0.5

CARDIAC ACTIVITY

LV FAILURE

LUNG ROCKETS

RV STRAIN

EFFUSION /TAMPONADE

PNEUMOTHORAX (TENSION)

DVT

SOURCE?

Does it work?

• 15 mins after arrival to ED:– 50% correct diagnosis in clinical assessment group

– 80% correct diagnosis in ultrasound assessment group

• Scan time - 5.8 mins» Jones, A. CCM 2004;32(8):1703

Marker Conventions

Formal Echocardiography

What do we need to assess?• Pericardial effusion / tamponade

• Gross ventricular function» Normal

» Hypokinetic

» Hyperdynamic

• Atrial & ventricular size

Subcostal Echo

• Don’t need an echo probe– Can used curved array

• Suited to supine patients

Subcostal Echo

Liver

RVLV

‘Backup’ Views

• Long axis

• Short axis

• Apical

Parasternal Long Axis

RV

LVLA

Ao

Parasternal Short Axis

LVRV

Parasternal Short axis

Text

Echo made easy

S.Kaddoura

Parasternal

Short axis

Apical Four Chamber

LVRV

IVC Assessment

IVC Collapsibility

• M Mode

• Collapsibility index

Why assess IVC?

Reasonable Preload assessment

In reality, the middle is a grey zone.

- Flat, collapsing >50% or less than 1.5 cm diameter

Hypovolemia!!!

Distributive Shock

- Engorged, >2 cm, poorly collapsible IVC

Obstructive Shock: think PE, Tamponade

Cardiogenic: think Acute/Chronic, Acute on Chronic

NB: though well correlated with central pressure, not a good

predictor of fluid responsiveness

Chest - Haemothorax

Will identify pleural effusions

Lung Bases

Reliably detects as little as 50-100ml in the thorax

Sensitivity >96%, specificity 99-100%

Effusion assessment

Liver

Diaphragm

Pleural space

Haemothorax

liver

fluid

Pneumothorax

Summary - Shock Scan

Free fluid Abdominal

Pleural

Lung Pneumothorax

Aorta AAA

Pericardium

ECHO

IVC

Effusion Haemopericardium

Tamponade

Chamber size

Contractility

Collapsibility

Engorged

Others

• DVT

• Ruptured

ectopic

• Gallbladder

Clinical Cases

Case 1

• 67 year old female

• Presented following an episode of collapse

• 2 weeks increasing SOB and worsening ET

• 3 month Hx weight loss

• P - 115

• BP - 85/50

• RR - 22

• Temp 36.2

Hx

Obs • pH - 7.28

• Lactate - 5.2

• PaO2 - 9.6

• PaCO2 - 4.3

In

CXR

ECG

Differential?

Apical Echo

Drained 1.3L of exudate - malignant cells

Echo findings in Tamponade

• Effusion with diastolic collapse of any chamber

• Moderate / large effusion with clinical suspicion of tamponade

• Engorged, non-collapsible IVC

Case 2

• 58 year old male

• Blue call - OOH cardiac arrest

• PEA

• 4 x cycles CPR

• PMHx IHD

• DHx Amiodarone

Hx

PEA:‘True EMD’ vs Low CO state

• No mechanical activity very grave prognostic sign

– No survivors in series of 136

» Blavis, M. AEM 2001;8(6):616

Case 3

• 58 year old male

• Sudden onset chest pain and SOB

• Sedentary, lives in a single room

Hx

Obs In• P - 145

• BP - 75/50

• RR - 32

• pH - 7.28

• Lactate -

4.8

• PaO2 - 7.6

• PaCO2 - 4.1

CXR

ECG

Differential?

IVC

Echo

Diagnosis of massive PE

• RV dilatation (RV > LV)

• RV hypokinesis

• Paradoxical septal motion

– IVC engorgement (>2cm)

Case 4

• 81 yr old female

• Sudden onset chest pain

• Collapses in ambulance and has a seizure

• PEA Arrest

• 1cycle CPR + Fluid bolus

• P122 BP 64/- RR14

ECG

Diagnosis?

Ultrasound

CT

Case 5

• 56y old man

• Out playing poker

• Epigastric pain and dead leg

Case 6

• Morbidly obese 40yr old female

• 3 days Haemoptysis

• Hypotensive and tachycardic

• Previous DVT with multiple PEs

• Not anticoagulated

Vital Signs

• P119 BP 70/30

• RR22 SpO2 92% on 15LPM

• T 38.5

• ABG– pH 7.1

– PaCO2 6.2

– PaO2 7.5

– HCO3 14

– BE -10

ECHO / Ultrasound

• Underfilled IVC

• Normal RV

• Hyperdynamic circulation

• L lung base effusion

Investigations

Diagnosis

• Severe sepsis secondary to pneumonia

• Ultrasound diagnostic tap

Case 7

• 22 yr old female

• Collapse at home

• P 144 RR22 BP 76/52

• PEA arrest with LAS

FAST / SHOCK Scan

Diagnosis

• Ruptured ectopic

• Urgent laparotomy

21y Male ‘Silent Chest’

Questions?

Questions?

• Fate Card

• iPhone and Andriod