Disclosures Undifferentiated Hypotension - UCSF CME Sohoni RUSH_protocol.pdfUndifferentiated Hypotension Aparajita Sohoni MD Alameda Health System - Highland Hospital April 7, 2016

3/22/2016

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Undifferentiated Hypotension

Aparajita Sohoni MDAlameda Health System - Highland Hospital

April 7, 2016

Disclosures

• I have no relevant financial relationships to discloseI will not discuss any off-label use and/or investigational use in my presentation

• *Thanks to Arun Nagdev MD for use of slides/videos in preparation of this talk.

US Protocols for Shock

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RUSH

• Rapid Ultrasound for Shock and Hypotension

Outline

• What?

• Why?

• When?

• How?

• Cases

What is the RUSHexam?

• Rapid, systematic evaluation of:

- heart (pump)

- effective intravascular status (tank)

- arterial/venous circulation (pipes)

HIMAP

• Heart

• IVC

• Morison’s/FAST

• Aorta

• Pneumothorax

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Why do we do it?

• Assess etiology of shock

• Reversible causes of shock

• Guide resuscitation

Types of Shock

• Hypovolemic

• Cardiogenic

• Obstructive

• Distributive

When?

• Unexplained hypotension or shock

• Part of the primary resuscitation

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How to do the exam?

• Start with the heart and IVC

• Add components as clinically indicated

HIMAP

• Heart

• IVC


• Aorta

• Pneumothorax

HIMAP++(pump, tank, pipes)

• Heart

• IVC


• Aorta

• Pneumothorax

• Lungs for pulmonary edema

• Legs for DVT

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Heart

• Three questions:

- Pericardial effusion/tamponade?

- RV failure (massive PE)?

- Qualitative assessment of LV function?

Cardiac Views

• Parasternal long and Apical 4-chamber

• Small footprint probe (3-5MHz)

QuickTime™ and aH.264 decompressor

are needed to see this picture.

LVLVRVRV

Parasternal Long Axis View

LVLV

RVRV

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Pericardial effusion




are needed to see this picture. QuickTime™ and aVC Coding

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QuickTime™ and aVC Coding


QuickTime™ and aMicrosoft Video 1 decompressorare needed to see this picture.

Pericardial vs. Pleural Fluid

• Descending thoracic aorta

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Pleural effusion

Descending Thoracic

Aorta Image source: https://sonospot.wordpress.com Image source: https://sonospot.wordpress.com

Pericardial effusion

Descending Thoracic

Aorta


Pericardial Tamponade• Collapse of the RV during early diastole

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Pericardial Tamponade






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Heart









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Heart





QuickTime™ and aDV/DVCPRO - NTSC decompressor




Normal Low EF

Normal vs. Hypodynamic Left Ventricle

QuickTime™ and aDV - NTSC decompressor


Poor EF



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EPSS

• E-point to septal separation (EPSS)

• E wave: Early Filling Phase

- during diastole, initial wave of blood that enters the left ventricle from the left atrium (70-80%)

- A wave: “atrial kick”

- normal EPSS is less than 8-10mm



NormalAbnormal


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Fractional Shortening

• Another way to estimate EF

• Correlates to overall LV contractility

• FS of 30-45% = normal LV contractility

• [EDD-ESD/EDD] x 100

Image source: https://sonospot.wordpress.com

Image source: https://sonospot.wordpress.com





Normal Low EF

Normal vs. Hypodynamic Left Ventricle

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Hyperdynamic LV

• LV walls change >90% between systole and diastole

• LV walls touch at end-systole



Heart


✓Pericardial effusion/tamponade?

✓RV failure (massive PE)?

✓Qualitative assessment of LV function?

HIMAP

✓Heart

• IVC


• Aorta

• Pneumothorax

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HIMAP

• Heart

• IVC


• Aorta

• Pneumothorax

IVCIndicator toward chinAim towards thoracic

spine

RA

IVC

IVCImage the

IVC entering Right Atrium



IVCIVC

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• Assess for IVC fullness

• Assess for collapse with inspiration

- 2-3cm inferior to right atrial junction

• Note collapsibility

IVCGoals

QuickTime™ and aTIFF decompressor


QuickTime™ and aTIFF decompressor


cephalad caudad

diaphragm

RA border

cephalad caudad

diaphragm

RA border

IVCi IVCe

liver liver

Expiration

IVC

Inspiration

2-3 cm







IVC & CVP

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IVC vs Aorta





• Empties into heart ● Flows deep to heart

• Flows through liver ● Flows deep to liver

• Undulating Pulsation ● Bounding Pulsation

Pitfalls:

Can’t find the IVC?

• Use the internal jugular veins

• Note collapsibility during respiratory cycle

Image source: Seif et al. CCRP

HIMAP

✓Heart

✓IVC


• Aorta

• Pneumothorax

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1. Hepatorenal -Morison’s*

2. Splenorenal*

3. Suprapubic

3

441 2

FAST Exam

*include thoracic views

Morison’s Pouch



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Don’t forget the pleural space!

1. Hepatorenal -Morison’s*

2. Splenorenal*

3. Suprapubic

3

441 2

FAST Exam

*include thoracic views

Splenorenal Recess

Spleen

Kidney

Hyperechoic Diaphragm

Costophrenic recess


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Don’t forget the pleural space!

Suprapubic

Transverse Longitudinal

Pelvic View Transverse:

Male

Abnormal

Pelvic View Transverse: Female

Abnormal

Abnormal

Uterus

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Pelvic View Longitudinal:

Male

Abnormal

Pelvic View Longitudinal: Female

Abnormal

HIMAP

✓Heart

✓IVC

✓Morison’s/FAST

• Aorta

• Pneumothorax

Aorta

• 2 dimensions

• Image through the bifurcation

• Look for AAA or dissection

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HIMAP

✓Heart

✓IVC

✓Morison’s/FAST

✓Aorta

• Pneumothorax

Pneumothorax

• Linear transducer

• Indicator towards the head

• Anterior intercostal spaces

• Bilateral



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Image source: Seif et al. CCRP

HIMAP

✓Heart

✓IVC

✓Morison’s/FAST

✓Aorta

✓Pneumothorax


• Heart

• IVC


• Aorta

• Pneumothorax


• Legs for DVT

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Pulmonary Edema



Acute Interstitial Syndrome

Arise from the pleural line

Well-defined

B lines = interstitial syndrome

B lines = interstitial syndrome

Move with lung slidin

3 per rib space

Reach screen edge




A Lines B Lines

Normal Lung

COPD

Asthma

Pulmonary Edema

Pneumonia

Interstitial Fibrosis

ARDS

Lung Contusion



B lines = increased fluid in the interstitium

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are needed to see this picture.QuickTime™ and a

H.264 decompressorare needed to see this picture.

A lines = Dry

B lines = WetB lines = Wet



A lines = DryA lines = Dry




• Heart

• IVC


• Aorta

• Pneumothorax


• Legs for DVT

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Overwhelmed?

• Don’t have to do everything on everyone

• Start with heart and IVC on everyone

Outline

• What?

• Why?

• When?

• How?

• Cases

Case 1

32 y/o Dev. Delayed maleCode 3 by EMS

SVT and respiratory distress

Phonating

Decreased BS on Left base

Extreme TachyIrregular rhythm

Pulses weak

No Edema

HR 242 BP 90/palp RR 34 SaO2 90%

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ED Course

• Pacer pads placed.

• Adenosine drawn up.

• Ultrasound machine to the bedside.

Bedside Echo, Apical




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Echo findings:

• Pericardial effusion: Huge

• Cardiac Function: Hyperdynamic LV

RV collapse

• Central Venous: HighPressure

= Impending Tamponade

Case 2

83 y/o MCHF, LVEF 20%

Febrile, HypotensiveAltered

BP 88/50 HR 110 R 18 O2 96% T 101.3

Phonating, Mumbling

Bibasilar RalesNml chest rise

TachyReg rhythm

Pulses weak

2+ Pitting Edema

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Parasternal Long Axis



Parasternal Short Axis



Apical 4 Chamber

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IVC

Echo findings:

• Pericardial effusion: No

• Cardiac Function: Depressed LV Fxn

• Central Venous: Low/NormalPressure

= Give me fluids

Case 3

46 y/o F with no PMHPalpitations and Dyspnea

BP 80/40 HR 152 R 32 O2 90% T 98.4

Speaking Full Sentences

CTA BKussmaul

Respirations

TachyReg rhythm

Pulses Normal

No Edema

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Parasternal Long Axis

RV - Large &Hypokinetic

LV - Small &Hyperkinetic

Normal





Parasternal Short Axis

“D”-ShapedLeft Ventricle

D



(Septal Wall Flattening)

Normal





RVD:LVD >1(normal<1)



Apical 4 ChamberNormal

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IVC

IVC= Plethoric(Full, Stiff)

Echo findings:

•Pericardial effusion: No

•Cardiac Function: Hyperdynamic LVRV Dysfunction

• (RV dilation, Pulm HTN)

•Central Venous: HighPressure=High Suspicion for Submassive Pulmonary

Embolism

Conclusions

• Valuable tool for evaluation of critically ill hypotensive patients

• Become comfortable with heart and IVC views; add on more as you go

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Where can I learn more?

• Weingart S, et al. The RUSH Exam: Rapid Ultrasound for Shock and Hypotension (http://emcrit.org/rush-exam/)

• Seif D, Pereira P, Mailhot T, et al. Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. Crit Care Research & Practice. August 2012.

• Sonospot.wordpress.com (cases & review)

Questions?

Documents

Disclosures Undifferentiated Hypotension - UCSF CME Sohoni RUSH_protocol.pdfUndifferentiated Hypotension Aparajita Sohoni MD Alameda Health System - Highland Hospital April 7, 2016