2015-01-31

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Why is my patient crashing?

Point-of-care ultrasound forclinical problem solving

Jordan Chenkin

Objectives

• Review POCUS algorithm for undifferentiatedshock

• Apply algorithm to problem solve difficultemergency cases

• Convince you that you need to start doing this

Undifferentiated Shock RUSH Exam for Undifferentiated Shock

• Heart• IVC• Morison’s• Aorta• Pneumo

H - Heart

LV contractility

Pericardial effusion

RV strain

I - IVC

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M - Morison’s A - Aorta

P - Pneumothorax Case 1

“MD to Resus”

• 59F BIBA into Resus room• EMS:

– Diarrhea x 3 weeks, poor intake– ‘Diverticulitis flareup’– Today – syncope -> EMS– Hypotensive 60/p throughout transport– PMH: diverticulitis, asthma

1830h: Initial Assessment

• HR 130 BP 64/19 RR 30 T 36.8 Sat ?• Pale, looks unwell• Speaking, protecting airway• Decreased AE bilaterally• Normal heart sounds• Abdomen obese, tender LLQ, no peritonitis

• Other info?

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Management

• IV x2, O2, monitor, ECG, glucose• Airway equipment ready• Draw labs• Call RT• Call CXR

Management of Hypotension?

• Give some fluids• Maybe give some more?• Start some pressors

Case continued

• 2L NS over 20 minutes• Ceftriaxone + metronidazole IV• Repeat vitals: HR 160 BP 70/50 RR 24 Sat ?• Decreasing LOC

• What is going on?

ECG

CXR Plan?

• Intubation?• More fluid?• Pressors?• CT?• Other?

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Case

• Patient intubated• PEA arrest• CPR, epinephrine -> ROSC• Vitals: BP 60/30 HR 60 Sat 100% EtCO2 16

Case

• 2005h: Alteplase 100mg IV bolus• 2013h: BP 105/60 HR 120 Sat 96%• 2115h: CT

2130h: CTPA 2130h: CTPA

Massive Pulmonary Embolism

• Definition– SBP < 90 mmHg– Drop of 20-40mmHg

for >15 mins• Mortality highest

within 1-2h of onset• Frequently undiscovered until autopsy

How can POCUS help?

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1. Heart2. Lung3. Veins

RV Dilation

• Sensitivity 50%• Specificity 98%

Lung Ultrasound

• Sensitivity 61%• Specificity 96%

DVT Ultrasound

• Sensitivity 53%• Specificity 98%

Sensitivity 90%Specificity 86%

Embolism in Transit

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Embolism In Transit Why was patient getting worse?

Bottom Line: Patient in Shock? Case 2

• 65M with chest pain x 3h• Initially 8/10 – now 5/10• PMH healthy• No meds, NKA• 104/51 HR 89 RR 16 T 35.0 99% r/a• Looks well• Normal exam

Initial ECG Case

• Pain now getting worse• BP 70/30 RR 26 HR 80 Sat 92%• Decreasing LOC• Repeat examination – crackles bilaterally• JVP elevated

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Repeat ECG Plan?

• Intubate?• Antiplatelet/anticoagulate?• CXR?• Cardiology?• Thrombolysis?• Pressors?• Other?

Case

• Patient intubated• Vascular surgery consult• Taken to CT

2215h: CTA

2215h: CTA 2215h: CTA

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Aortic Dissection

• 3-5 cases per 100,000/yr• Misdiagnosis up to 50%• Mortality 1% per hour (type A)

• However 80% survival if early dx/tx • Sensitivity 54% (39-68%)• Specificity 94% (90-97%)• Sensitivity 100% for pts in shock

Intern Emerg Med (2014) 9:665–670

Direct Sign: Intimal Flap Direct Sign – Flap (Arch)

Direct Sign – Flap (Carotid) Direct Sign: Flap (abdomen)

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Indirect Sign: AI Indirect Sign: Aneurysm

Case Continued

• 3h delay to OR• Patient arrested on induction• Pronounced 6h after arrival

Case 3

• 82 M brought into resus• Increasing SOB x 3-4 days• Now severe SOB• Increasing leg edema, orthopnea• PMH: CHF (Grade 3 LV), HTN, COPD• Meds: furosemide 40mg, fosinopril,

pravastatin, salbutamol

Case 3

• T 36.0 HR 110 RR 32 BP 173/109 96% NRB• Severe respiratory distress• Crackles and wheezes bilaterally• Pitting edema to thighs bilaterally• JVP elevated

ECG

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CXR Plan?

• NTG?• Bronchodilators?• Lasix?• ACEi?• BiPAP?• Intubation?• Other?

Case

• NTG x 2• BiPAP• BP 72/30 HR 135 RR 40 Sat 88%• Decreasing LOC• Looking pre-arrest

• What is going on?

Cardiac Tamponade

• 103 patients with unexplained SOB after fullworkup

• 13.6% had unsuspected PCE• 4% had large PCE requiring drainage

Pericardial Effusion

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RV Diastolic Collapse

Sens 60%Spec 100%

RA Systolic Collapse

Sens 94%Spec 100%

Swinging Heart Sniff Test

Sniff Test Case

• Fluid bolus given• BP 66/30 HR 140 RR 30 Sat 90%

• Plan?

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Identify Target Site

• Shortest distance to fluid

• Will be transthoracic 80% of time

Insert Needle - Transthoracic

• If possible – from MEDIAL to LATERAL

Insert Needle – Lateral Approach Pericardiocentesis

Tips – Agitated Saline Case Resolution

• Successful pericardiocentesis• Removed 100cc serous fluid• Rapid improvement in hemodynamics• Discharged 2 days later

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Summary

• RUSH algorithm for undifferentiated shock• Occasionally unexpected findings• Beware of premature closure• Easy techniques to learn and apply