Emergency Ultrasound (EUS)教學(15)

急診超音波在休克評估之應用
新光醫院急診醫學科
陳國智醫師
中華民國醫用超音波學會指導醫師
ACEP 2008 EUS guidelines

Ann Emerg Med. 2009;53:550-570

 Severity of ED hypotension predicts
adverse outcome

SBP <100
SI >1

Shock 2004
ED hypotension is a risk for death
(Def: SBP < 100)

Exposure n = 887 8.3% death

Non-exposure n = 3903 2.8% death Chest 2006
 The more severe and prolonged the
hypotension, the higher the risk of death

6x

OR 5.4 3.2 2.0

Chest 2006
 UHP Ultrasound Protocol
(Undifferentiated Hypotensive Patient)

1. Free intraperitoneal fluid evaluation

2. Focused cardiac examination
3. Focused abdominal aorta
evaluation
Am J Emerg Med 2001
3 Scanning of UHP protocol

Am J Emerg Med 2001

IVC scanning

Am J Emerg Med 2005

IVC diameter after donation

Am J Emerg Med 2005

IVC as a marker of blood loss
31 volunteers (18 M)
Mean age: 49.5 y ( 18-73)
450ml donation within 30min

Before (mm) After (mm) Change △

IVCe 17.4 11.9 5.5
IVCi 13.3 8.13 5.16

Am J Emerg Med 2005

 Goal-directed US for nontraumatic
hypotension in ED
• 1. Subcostal view
– Cardiac tamponade
• 2. Inferior vena cava (IVC) view: Collapsibility 50%
– Intravascular volume status
• 3. Parasternal long cardiac view
– LV function and pericardial effusion
• 4. Apical four-chamber cardiac view
– Ventricular size and LV function
• 5. Hepatorenal recess view
– Free intraperitoneal fluid
• 6. The pelvis and retrovesical view
– Free intraperitoneal fluid
• 7. Abdominal aorta view
– Any diameter >3 cm

CCM 2004
 SBP <90
Shock index >1
One s/s of shock

Diagnosis accuracy
80% vs 50%

CCM 2004
Abdominal and Cardiac Evaluation
with Sonography in Shock (ACES)
protocol

EMJ. 2009;26;87-91
ACES protocol

EMJ. 2009;26;87-91
IVC with collapse index

EMJ. 2009;26;87-91
Dilated right ventricle

EMJ. 2009;26;87-91
Pericardial fluid

EMJ. 2009;26;87-91
Haemoperitoneum/ peritoneal fluid

EMJ. 2009;26;87-91
AAA

EMJ. 2009;26;87-91
IVC & RAP

EMJ. 2009;26;87-91
EMJ. 2009;26;87-91
 The RUSH Exam
Rapid Ultrasound in SHock
in the Evaluation of the Critically l l l

Step 1: The pump

Step 2: The tank
Step 3: The pipes

Emerg Med Clin N Am 28 (2010) 29–56

RUSH Step 1: Evaluation of the Pump

A. Parasternal views
– Long/ short axis

B. Subxiphoid view

C. Apical view

Emerg Med Clin N Am 28 (2010) 29–56

RUSH Step 1: Evaluation of the Pump

• ‘‘Effusion around the pump’’

– evaluation of the pericardium
• ‘‘Squeeze of the pump’’
– determination of global left
ventricular function
• ‘‘Strain of the pump’’
– assessment of right ventricular
strain

Emerg Med Clin N Am 28 (2010) 29–56

RUSH Step 2: Evaluation of the Tank

A. IVC long axis

B. FAST/RUQ
– Add pleural view
C. FAST/LUQ
– Add pleural view
D. FAST/Pelvis
E. Pneumothorax
Pulmonary edema

Emerg Med Clin N Am 28 (2010) 29–56

RUSH Step 2: Evaluation of the Tank

• ‘‘Fullness of the tank’’

– evaluation of the inferior cava
and jugular veins for size and
collapse with inspiration ，F/U
• ‘‘Leakiness of the tank’’
– FAST exam and pleural fluid
assessment
• ‘‘Tank compromise’’
– pneumothorax
• ‘‘Tank overload’’
– pulmonary edema

Emerg Med Clin N Am 28 (2010) 29–56

RUSH Step 3: Evaluation of the Pipes

A. Suprasternal aorta
B. Parasternal aorta
C. Epigastric aorta
D. Supraumbilical aorta
E. Femoral DVT
F. Popliteal DVT

Emerg Med Clin N Am 28 (2010) 29–56

RUSH Step 3: Evaluation of the Pipes

• ‘‘Rupture of the pipes’’

– aortic aneurysm and
aortic dissection
• ‘‘Clogging of the
pipes’’
– venous
thromboembolism

Emerg Med Clin N Am 28 (2010) 29–56

Ultrasound, a tool for the
clinical examination
It is only by
thorough history taking and physical
examination
that one can propound a diagnosis

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