AAENP US WORKSHOP 2/25/17
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1 Know the components of the Rapid Ultrasound for Shock & Hypotension & Extended Focused Assessment Sonography in Trauma & how they can help quickly determine diagnosis. Be comfortable obtaining and interpreting bedside images in the crashing patient. Rapid Ultrasound for Shock & Hypotension & Extended Focused Assessment Sonography in Trauma Emory Critical Care Center Atlanta, GA Sick Medical Pt = RUSH Sick Trauma Pt = FAST Bri Perry, ACNP & Lesley Burnett, ACNP Distributive Hypovolemic Distributive Hypovolemic Cardiogenic Cardiogenic Obstructive Obstructive Bri Perry, ACNP & Lesley Burnett, ACNP Bri Perry, ACNP & Lesley Burnett, ACNP 1
2 You can knock out a lot of your differentials and determine optimal treatment. Heart IVC Aorta Morrison s Pouch (FAST) Pneumothorax Heart PLAX & A4C views (Or subcostal) LV Function/Contractility Pericardial Effusion & Tamponade RV strain (PE) à RV >LV; D-shaped LV IVC Preload; ~CVP Hypovolemia / Distributive Spontaneous: collapses w/ inspiration/sniff Mech Vent: expands w/ inspiration 10cc/kg Fat & Full CVP > 15 Thin & Flat: CVP <5 2
3 Aorta Four cross-cut (transverse) sections of the aorta (slide probe down from xiphoid to umbilicus) Just below the heart Suprarenal Infrarenal Just before iliac bifurcation If Aorta >5cm, pt in shock has ruptured AAA until proven otherwise. Morrison s Pouch (FAST) FAST EXAM: Eval RUQ/LUQ/pelvis for free fluid RUSH EXAM: Trendelenberg + RUQ US exam = high sens/spec for finding free fluid Slide up to diaphragm to for pleural effusions bilat Remember what free fluid can be what s the HPI/PMH? ascites, ruptured viscus, rupture of an AAA Pneumothorax Lung sliding rules out PTX Lung point is 100% sensitive for PTX (try to find it if you don t see sliding!) For Echo Views: For Non- CardiacViews: 1) PLAX 2) A4C 3) Subcostal/IVC 4) Aorta 5) Morrison s Pouch/RUQ 6) Lung 7) Lung 3
4 For Non- CardiacViews: 1) SC 2) RUQ 3) LUQ 4) Pelvic Gutter 5) Lung 6) Lung Shock Cardiac IVC Treatment Septic Hyperdynamic Thin & Flat IVF +/- pressors Cardiogenic Hypodynamic LV Fat & Full Inotropes Hypovolemic Hyperdynamic LV Thin & Flat IVF/Blood Tamponade PE Pericardial Effusion, Diastolic Collapse of RA/RV Dilated RV; RV > LV; visible clot Fat & Full Fat & Full Ultrasound-Guided Pericardiocentesis Thrombolysis or Surgical Embelectomy 1. Practice the RUSH exam on your patients. 2. Learn what normal looks like so you can recognize abnormal. 3. If a pt has a known problem, such as EF 10%, go put the probe on! 4. Suggest bedside US in rounds for others pts (so many times it could be helpful.) **Your mission, if you choose to accept it, RUSH one of your patients this week. ** 4
5 The RUSH Exam - Rapid Ultrasound for Shock / Hypotension ( Download these free ibooks on US. Great resource! Lodato JA, Ward RP, Lang RM. Echocardiographic predictors of pulmonary embolism in patients referred for helical CT. Echocardiography 2008, Jul;25(6): Barbier C, Loubières Y, Schmit C, Hayon J, Ricôme JL, Jardin F, Vieillard-Baron A. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med 2004, Sep;30(9): American Society of Echocardiography Guidelines 5
6 Bri Perry, ACNP Emory Critical Care Center Atlanta, GA 6
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University of Wisconsin - Madison Cardiovascular Medicine Fellowship Program UW CICU Rotation Goals and Objectives
Background: The field of critical care cardiology has evolved considerably over the past 2 decades. Contemporary critical care cardiology is increasingly focused on the management of patients with advanced
ENDPOINTS OF RESUSCITATION
ENDPOINTS OF RESUSCITATION Fred Pieracci, MD, MPH Acute Care Surgeon Denver Health Medical Center Assistant Professor of Surgery University of Colorado Health Science Center OUTLINE Recognition and characterization