ultrasound in icu and emergency
TRANSCRIPT
Ultrasound in ICU
and Emergency
Gamal Agmy, MD, FCCP Professor of chest Diseases, Assiut university, Assiut, Egypt
Bedside Chest Radiography in the
Critically ill Patients
At the bedside, chest radiography remains the
reference for lung imaging in critically ill patients.
However, radiographical images are often of limited
quality
Risk of transportation
Lung Computed Tomography in
the Critically ill
02 09 2012
Transthoracic
Sonography
(Daniel A. Lichtenstein , MD , FCCP, CHEST
2015; 147 ( 6 ): 1659 - 1670
THE BAT VIEW
Chest wall
Pleural line
Normal lung surface
A lines = default normal
Horizontal echo
reflection at exact
multiples of intervals
from surface to
bright reflector.
Dry lung OR PNTX
Decay with depth
Obliterated by B
pleura A
A
A
A
A
A
the "seashore sign" (Fig.3).
• Absent lung sliding
• Exaggerated horizontal artifacts
• Loss of comet-tail artifacts
• Broadening of the pleural line to a band
• Lung point
• Loss of lung impulse
The key sonographic signs of
Pneumothorax
Confluent B lines = Bad Bad
‘White’ or ‘shining’
lung
Means increased
severity
Probably indicates
thicker fluid in alveoli
eg protein or
inflammatory cells
% space / 10
B x 3 x 2 x 2 = CCF
Makes assumption that ‘globally’ wet
lungs are most likely to be CCF
12
INTERSTITIAL SYNDROME
INTERSTITIAL SYNDROME
PULMONARY EMBOLISM
PULMONARY EMBOLISM
Schematic representation of the parenchymal, pleural and vascular
features associated with pulmonary embolism.(Angelika Reissig, Claus
Kroegel. Respiration 2003;70:441-452 )
PE DIAGNOSTIC ACCURACY
LUS for diagnosis of PE
Metaanalysis:
- Sens.: 80% (75-83%)
- Spec.: 93% (89-96%)
Niemann T et al. Transthoracic sonography for the detection of pulmonary embolism–a meta-analysis. Ultraschall Med 2009 30:150–156
Ultrasound profiles.
Lichtenstein D A , Mezière G A Chest 2008;134:117-125
Tissue pattern representative of Alveolar
Consolidation
Presence of hyperechoic punctiform images representative of air bronchograms
Pleural effusion
Lower lobe
FLUS: IS PRESENT? YES/NO
Normal pattern IS pattern
Cardiogenic pulm. edema:
Excluded – COPD exa?
Cardiogenic pulm. edema:
Suspected
BLUE-Protocol and FALLS-Protocol
Two Applications of Lung Ultrasound
in the Critically Ill
(Daniel A. Lichtenstein , MD , FCCP, CHEST
2015; 147 ( 6 ): 1659 - 1670
IVC Sonography
INDICATIONS
IVC Ultrasound
Spontaneously
Breathing
Mechanical
Ventilation
Volume Status / CVP Fluid Responsiveness
Respiratory variation
Expands w/ expiration
Contracts w/ inspiration
Due to changing intrathoracic pressures.
PROCEDURE Probe Selection
1 Low frequency 2-5 MHz
2 Curvalinear probe
Where to put the probe…
Supine position
Subxiphoid
Orientate probe in
longitudinal plane with
probe indicator to
patient’s head
Slightly to right of
midline
PROCEDURE
Xiphoid View
IVC Longitudinal
PROCEDURE
Anterior -Mid-Axillary View
IVC Anterior Mid-Axillary View
Inspiratory (Minimal) IVC
Diameter
Maximum (Expiratory) IVC
Diameter
M-Mode IVC Diameters
CAVAL INDEX (CI)
CI =
minimal (inspiratory)
diameter
maximum (expiratory)
diameter
maximum (expiratory)
diameter
CAVAL INDEX (CI)
Volume
Depletion
Volume
Overload
0% 100%
IVC v CVP
Correlation Between IVC Diameter Plus CI and
CVP
IVC Max Diameter
(cm)
CI CVP
(mmHg)
< 1.5 100%
(total collapse) 0-5
1.5-2.5 > 50% 6-10
1.5-2.5 < 50% 11-15
> 2.5 < 50% 16-20
> 2.5 0%
(no collapse) >20
Echocardiography
Parasternal long axis
Transducer at left sternal
edge between 2nd -4th
intercostal space
Probe marker pointing to
patients R shoulder
Probe aligned along the
long axis: from R shoulder
to cardiac apex.
Useful view to assess contractility
Apical 4 chamber
Transducer at 4th-6th intercostal space in the midclavicular to anterior-axillary line.
Probe directed towards patient’s right shoulder with the marker directed towards the left shoulder.
Important view to give relative dimensions of L and R ventricle.
Normal ventricular diameter ratio of R ventricle to L ventricle is <0.7.
Pericardial Tamponade
Remember tamponade is a clinical diagnosis based on patient’s haemodynamics and clinical picture.
Ultrasound may demonstrate early warning signs of tamponade before the patient becomes haemodynamically unstable.
Haemodynamic effects
Its PRESSURE NOT SIZE THAT COUNTS!
Rate of formation affects pressure-volume relationship and is therefore more important than volume of fluid.
Tamponade using ultrasound
A moderate-large effusion.
Right atrial collapse
Atrial contraction normal in atrial systole
Collapse throughout diastole or inversion is abnormal.
RV collapse during diastole when meant to be filling (‘scalloping’ seen)
