急诊超声对于休克患者的鉴别诊断课件

急急诊超声超声对于休克患者的于休克患者的鉴别诊断断(刘刘继海海)急诊超声对于休克患者的鉴别诊断(刘继海)急诊超声对于休克患者1主要内容主要内容急诊超声和普通超声的区别？以不明原因休克患者RUSH检查为例进一步阐释急诊超声的重要性急诊超声的未来发展方向？主要内容急诊超声和普通超声的区别？2急诊超声技术的开展带来的冲击急诊超声技术的开展带来的冲击“争地盘”或“抢饭碗”该不该做？“资质问题”与“收费问题”如何做？“难做吗”与“做得准吗”培训与质量控制如何解决？急诊超声技术的开展带来的冲击“争地盘”或“抢饭碗”该不该3急诊超声急诊超声 vs.vs.普通超声普通超声急诊医生床旁超声检查旨在最短的时间内得到明确的诊断线索（带着问题进行超声检查）:患者各浆膜腔有液体吗?患者有腹主动脉瘤吗?患者有宫内妊娠吗?患者有深静脉血栓吗?患者的心脏在收缩吗?正常还是异常?急诊超声 vs.普通超声急诊医生床旁超声检查旨在最短的时间4急诊超声应用范畴急诊超声应用范畴表2.1 CCEP急诊超声基本应用 2013创伤超声重点评估腹主动脉超声重点评估心脏急诊重点超声超声引导操作技术气道急诊超声评估表2.2 CCEP急诊超声高级应用 2013肺急诊重点评估外周血管急诊重点评估腹部急诊重点评估妇产科急诊重点评估阴囊急诊评估眼睛急诊评估急诊超声应用范畴表2.1 CCEP急诊超声基本应用 2015与医疗质量息息相关与医疗质量息息相关危重患者的快速有针对性的超声检查，提高诊断效率:FAST,AAA,Cardiac in PEA or hypotension改进患者的流程，减少急诊滞留时间:DVT,Pelvic sono in early pregnancy帮助我们完成一些操作，降低风险:Central lines,abscesses,LPs与医疗质量息息相关危重患者的快速有针对性的超声检查，提高诊断6急急诊诊超声有超声有别别于于传统传统的超声的超声检查检查传统的超声检查更加注重某个脏器病变的检查和描述，急诊超声则从临床出发，有目的的对急诊患者进行超声的重点扫查，对于患者的疾病状态和脏器功能状况做出更为直观的评价，并根据检查的结果对患者进一步治疗和处置提出指导意见。由急诊医师主导的超声检查技术，被誉为“急诊医师的可视听诊器”评估危重症患者病情、对于危及生命的急诊疾病做出快速的诊断提高了急诊患者的诊治效率 引导临床侵入性操作及指导相关急诊状况的处置等，有效降低了侵入性操作并发症的发生率急诊超声有别于传统的超声检查传统的超声检查更加注重某个脏器病7病例病例24岁女性，58公斤，既往健康，仅口服避孕药。因“晕倒”被急救车送入院。病人意识模糊，病史有限。GCS（格拉斯哥昏迷评分）5-6，BP 73/42，脉搏80次/分，体温38.3，SpO292%（在吸氧4升/分钟的情况下），呼吸26次/分，大汗，右小腿及脚部明显肿胀。胸片无明显异常。心电图窦性心律，血糖4.3mM/L。病例24岁女性，58公斤，既往健康，仅口服避孕药。因“晕倒”8可能的诊断可能的诊断Left ventricular failureTension pneumothoraxHemoperitoneumAnaphylaxisSevere dehydrationNeurogenic shockCardiac tamponadeValvular dysfunctionPulmonary embolusOccult medication error or overdoseSepsisRuptured aneurysmAortic dissectionMyocardial ischemia/infarctionThyrotoxicosisAdrenal failureDysrhythmiaAutonomic dysfunctionOccult gastrointestinal bleedMesenteric ischemiaAbdominal inflammation可能的诊断Left ventricular failureT9RUSH ExamThis technology is ideal in the care of the critical patient in shock,and the most recent ACEP guidelines further delineate a new category of resuscitative ultrasound.Step 1:The pump（泵）Step 2:The tank（血容量）Step 3:The pipes（血管）RUSH ExamThis technology is id10急诊超声对于休克患者的鉴别诊断课件11Step 1Evaluation of the PumpEffusion around the pump:evaluation of the pericardiumSqueeze of the pump:determination of global left ventricular functionStrain of the pump:assessment of right ventricular strainStep 1Evaluation of the Pump12Evaluation of the PumpEvaluation of the Pump13Normal subxiphoidNormal subxiphoid14Normal parasternal longNormal parasternal long15Normal parasternal shortLateral wallNormal parasternal shortLatera16Normal parasternal short at level of aortic valveNormal parasternal short at l17Normal apical 4Lateral wallNormal apical 4Lateral wall18Normal apical 2Anterior wallNormal apical 2Anterior wall19Pericardial effusionPericardial effusion20Cardiac tamponadeCardiac tamponade21Squeeze of the pumpdetermination of how strong the pump is?”a visual calculation of the percentage change from diastole to systoleMotion of anterior leaflet of the mitral valve can also be used to assess contractility.Squeeze of the pumpdetermi22Normal parasternal longNormal parasternal long23Normal parasternal shortLateral wallNormal parasternal shortLatera24An easy system of grading To judge the strength of contractions as good,with the walls of the ventricle contracting well during systole;Poor,with the endocardial walls changing little in position from diastole to systole;Intermediate,with the walls moving with a percentage change in between the previous 2 categories.An easy system of grading To j25BenefitsKnowing the strength of left ventricular contractility will give the EP a better idea of how much fluid the pump or heart of the patient can handle,before manifesting signs and symptoms of fluid overload.In cardiac arrest,the clinician should specifically examine for the presence or absence of cardiac contractions.BenefitsKnowing the strength o26Strain of the pumpOn bedside echocardiography,the normal ratio of the left to right ventricle is 1:0.6.The optimal cardiac views for determining this ratio of size between the 2 ventricles are the parasternal long and short-axis views and the apical 4-chamber view.Strain of the pumpOn bedsi27Right Ventricle StrainRight Ventricle Strain28Thrombus in RAThrombus in RA29Differential DiagnosisMassive PESmaller and recurrent pulmonary emboliCor pulmonalePrimary pulmonary artery hypertensionAcute right heart strain thus differs from chronic right heart strain in that although both conditions cause dilation of the chamber,the ventricle will not have the time to hypertrophy if the time course is sudden.Evaluation of the pipes”Differential DiagnosisMassive 30Step 2:Evaluation of the TankFullness of the tank:evaluation of the inferior cava and jugular veins for size and collapse with inspirationLeakiness of the tank:FAST exam and pleural fluid assessmentTank compromise:pneumothoraxTank overload:pulmonary edemaStep 2:Evaluation of the Tank31Evaluation of the TankEvaluation of the Tank32Fullness of the tankFullness of the tank33M-mode DopplerM-mode Doppler34How to determine？A smaller caliber IVC(2 cm diameter)that collapses less than 50%with inspiration correlates to a CVP of more than 10 cm of water。This phenomenon may be seen in cardiogenic and obstructive shock states.How to determine？A smaller cal35High cardiac filling pressureHigh cardiac filling pressure36Two caveats to this rule existThe first is in patients who have received treatment with vasodilators and/or diuretics prior to ultrasound evaluation in whom the IVC may be smaller than prior to treatment,altering the initial physiological state.The second caveat exists in intubated patients receiving positive pressure ventilation,in which the respiratory dynamics of the IVC are reversed.Two caveats to this rule exist37Leakiness of the tankFAST exam and pleural fluid assessmentIn traumatic conditions,as a result of a hole in the tank,leading to hypovolemic shock.In nontraumatic conditions,accumulation of excess fluid into the abdominal and chest cavities often signifies tank overload,In infectious states,pneumonia may be accompanied by a complicating parapneumonic pleural effusion,and ascites may lead to spontaneous bacterial peritonitis.Leakiness of the tankFAST 38Right upper quatrantRight upper quatrant39Left upper quadrantLeft upper quadrant40Pelvic free fluidPelvic free fluid41Tank compromise:pneumothoraxTank compromise:pneumotho42pneumothoraxpneumothorax43Tank overload:pulmonary edemaTo assess for pulmonary edema with ultrasound,the lungs are scanned with the phased-array transducer in the anterolateral chest between the second and fifth rib interspaces.The presence of B lines coupled with decreased cardiac contractility and a plethoric IVC on focused sonographic evaluation should prompt the clinician to consider the presence of pulmonary edema and initiate appropriate treatment.Tank overload:pulmonary e44B-linesB-lines45Step 3Evaluation of the PipesRupture of the pipes:aortic aneurysm and dissectionClogging of the pipes:venous thromboembolismStep 3Evaluation of the Pipes46AAAA measurement of greater than 3 cm is abnormal and defines an abdominal aortic aneurysmAAAA measurement of greater th47Aortic DissectionThe parasternal long-axis view of the heart permits an evaluation of the proximal aortic root,and a measurement of more than 3.8 cm is considered abnormal.Aortic DissectionThe parastern48Aortic DissectionAortic Dissection49Clogging of the pipes:venous thromboembolismClogging of the pipes:ven50SummarySummary51病例病例224岁女性，58公斤，既往健康，仅口服避孕药。因“晕倒”被急救车送入院。病人意识模糊，病史有限。GCS（格拉斯哥昏迷评分）5-6，BP 73/42，脉搏80次/分，体温38.3，SpO292%（在吸氧4升/分钟的情况下），呼吸26次/分，大汗，右小腿及脚部明显肿胀。胸片无明显异常。心电图窦性心律，血糖4.3mM/L。病例224岁女性，58公斤，既往健康，仅口服避孕药。因“晕倒52急急诊诊超声超声评评估估结结果（果（1）心脏收缩力好，未见明显心包积液，无右室劳损表现；下腔静脉直径50%，无浆膜腔积液主动脉正常，下肢静脉未见血栓，右下肢腹股沟区明显红肿右下肢蜂窝织炎，感染性休克右下肢蜂窝织炎，感染性休克急诊超声评估结果（1）心脏收缩力好，未见明显心包积液，无右室53急急诊诊超声超声评评估估结结果（果（2）心脏收缩力好，未见明显心包积液，无右室劳损表现；下腔静脉直径50%，盆腔积液，超声引导下穿刺抽出不凝血主动脉正常，下肢静脉未见血栓宫外孕破裂出血宫外孕破裂出血急诊超声评估结果（2）心脏收缩力好，未见明显心包积液，无右室54急急诊诊超声超声评评估估结结果（果（3）心脏收缩力好，未见明显心包积液，可见右室扩大表现，右室心肌不肥厚；下腔静脉直径=2cm，吸气变异率50%，未见多浆膜腔积液表现主动脉正常，下肢静脉可见血栓大面积肺栓塞可能大面积肺栓塞可能急诊超声评估结果（3）心脏收缩力好，未见明显心包积液，可见右55急急诊诊超声未来超声未来发发展方向展方向超声技术的发展带来变革更加注重脏器功能连续评估被越来越多的急诊医师所掌握并指导临床急诊超声未来发展方向超声技术的发展带来变革56急急诊诊医学的明天更美好医学的明天更美好急诊医学的明天更美好57谢谢！谢谢！谢谢！58