09/02/2011

How can echo help in shock?

Predict the response to fluid challenge Non-invasive CVP estimation Assess LV systolic function Structural cardiac assessment Examine the right heart

UNDIFFERENTIATED SHOCK
Stephen Glen

Case

Examination

32 yrs, female Abdominal pain Flu like symptoms for 48 hours PMH anxiety Collapsed at home 999 call Standby call to resus

GCS 11/15 (E4M4V3) SaO2 98% (air) BP 80/30, capillary refill 15 secs. HR 70/min (sinus) Chest clear Abdo- no guarding, no bowel sounds Heart sounds normal Macular rash across back and legs

A4ch. Focused echo.

PLAX

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LV function
1. Normal 2. Abnormal 3. Unsure

Estimation of CVP

Management
Estimated CVP IVC diameter (mm) < 20 < 20 > 20 > 20 > 50 < 50 < 50 0 % collapse Estimated CVP (mm H20) 5 10 15 20

Fluid resuscitation IV antibiotics Pelvic examination Clinical diagnosis toxic shock syndrome Why was she not tachycardic?

IVC m-mode

Be careful with M-mode of IVC

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Underfilled IVC

Distended IVC with no collapse

Caution
Small studies of specific cohorts to predict response to fluid, or PACWP Some patients ventilated, others not Some with known cardiac failure Part of overall clinical assessment

Case
54 yrs, male Dyspnoea and cough for one week Initially thought viral, attended GP who prescribed antibiotics Sudden deterioration at home Wife described dyspnoea, wheeze and then collapse No past medical history

Examination
Unconscious male, GCS 7 SaO2 81% (15 litres) BP 88/30, p 118/min (sinus) HS normal Chest bilateral reduced air entry, exp wheeze Intubated, remained hypotensive

Focused echo A4ch

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PSAX

IVC view

Echo assessment of fluid status

1. 2. 3. 4.

Management

Underfilled give IV fluid challenge Euvolaemic Overloaded not for IV fluids Unsure

Aggressive fluid resuscitation Wife arrived after ambulance Brought prescription from GP amoxycillin Previous rash with penicillin Treated with adrenaline, hydrocortisone, piriton Dx - Life threatening anaphylactic reaction to penicillin (confirmed by IgE reactivity)

Case
74 yrs, male Post-op left hemicolectomy (complete resection of Duke A colonic carcinoma) PMH- hypothyroidism (on thyroxine) and angina (well controlled) No anaesthetic complications Just arrived in HDU for post-op care Sudden onset chest pain, dyspnoea then circulatory collapse

Examination
Distressed and agitated, GCS 14 SaO2 97% (28% O2, 4 l/min)

BP 74/30 (arterial line) HR 107/min, sinus Chest clear HS normal Abdomen laparotomy scar

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Focused echo, A4ch

PLAX

A2Ch

Management
1. 2. 3. 4. 5.

Aggressive IV fluids IV diuretics Inotropes Back to theatre for exploratory laparotomy Unsure

Management
Central line examined 3 way connector incompletely attached Diagnosis- air embolism Management- line sealed, fluid resuscitation, high flow O2

Case
71 yrs, female Cough, pleuritic chest pain, rigors Background COPD, diabetes, renal impairment (eGFR 25), hypertension Huge list of medication (including enalapril, doxasosin, bendrofluazide, aspirin, inhalers, metformin) Started on augmentin and steroids 48 hrs ago

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Examination
Unwell, GCS 15 SaO2 91% (28%, 4 l/min) BP 80/48 P93/min (sinus) HS normal Chest poor air entry bilaterally, scattered wheeze and bibasal crackles Abdo normal

Focused echo

IVC view

Based on this limited assessment

1. For fluid challenge 2. Not for fluid challenge 3. Unsure

Management
Not given IV fluids CXR confirmed upper lobe diversion and bibasal consolidation

Case
65 yrs, male Chest pain, dyspnoea

Antihypertensives witheld 24 hrs of noradrenaline to maintain BP Broad spectrum IV antibiotics Good clinical progress

Took his wifes GTN spray and collapsed Ambulance called PMH- hypertension Rx- lisinopril and aspirin

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Examination
Pale, clammy, GCS 15 SaO2 96% (air) BP 76/30 P124/min (sinus) HS quiet Chest clear Abdo normal

Focused echo, PLAX

A4Ch

PSAX

PSAX

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Management
1. Presumed GTN syncope reassure and discharge if troponin negative 2. Fluid challenge 3. Inotropes 4. Cardiac surgery 5. Unsure

Management
Presumed GTN syncope Background antihypertensives ECG suggested LV hypertrophy Clinically undiagnosed aortic stenosis Formal echo confirmed critical calcific aortic stenosis Normal coronary arteries Successful aortic valve replacement

Case

Examination

27 yrs, male Rugby player Day case arthroscopy Sudden hypotension in recovery room No medical history Not registered with GP

GCS 11/15 (10 mins post-op) SaO2 99% (35% o2) P80/min, sinus BP 78/42 HS I + II + soft ESM Chest clear

Focused echo, PLAX

PSAX

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A4ch

Colour

Likely management
1. 2. 3. 4. 5.

Management

Anaphylaxis, for IV fluids, IM adrenaline Dehydrated, for IV fluids Pulmonary embolism, for thrombolysis Internal cardiac defibrillator Unsure

HOCM diagnosed by echo Cautious fluid resuscitation IV esmolol infusion Family screening & genetic analysis 24hr tape to risk assess VT identified ICD implanted, blocker started Has had to stop playing rugby

Case
24 yrs male, joyrider Lost control of car at around 80 mph, dual carriageway Head on collision with HGV Extracted by fire service Not wearing seat belt, air bag deployed Serious head injuries, bilateral humeral shaft fractures Likely blunt chest trauma

Progress
Aggressive fluid resuscitation, transfusion Skeletal survey- no sternal fracture Fractures stabilised CT bilateral occipital lobe contusion, small frontal haematoma, no cervical spine fracture Transferred to ITU for ventilation and post-op care

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Progress
Frequent ventricular ectopics Normal urea & electrolytes BP initially 110/64, drifting despite IV fluid and now noradrenaline

A4ch

PLAX

Diagnosis
1. 2. 3. 4.

Trivial pericardial fluid likely contusion Clinically significant pericardial effusion Pulmonary embolism secondary to trauma Unsure

Management
CT thorax confirmed partial pulmonary transection with leak of contrast into pericardium

Continual transfusion requirement Unstable transfer for cardiac surgery Successful repair of pulmonary root Eventual transfer to definitive rehab facility

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Case
33 yrs, female Sudden onset dyspnoea, palpitations Background of exertional dyspnoea Treated with inhalers but no improvement No siblings was adopted after mother died age 29 yrs (about six months post delivery) No other medical history

Examination
Pale, dyspnoeic, GCS 15 SaO2 91% (15 litres) BP 78/47 P190/min Chest bibasal and mid zone crackles HS fast

Management

DC shock with low dose propofol 200J VF 200J VF 360J sinus tachycardia (129/ min)

Focused echo

A4Ch

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A4Ch (subsequent echo with contrast)

Management
Initially stabilised with MgSo4 infusion Further VT, started on IV amiodarone Angiography normal Cardiac MRI confirmed echo appearances Non-compaction syndrome On cardiac transplant waiting list ICD implanted, anticoagulated Genetic markers

Non-compaction example, PSAX

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