心血管急症之應用

陳國智醫師

新光醫院急診醫學科

輔仁大學醫學系

中華民國醫用超音波學會指導醫師

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ACEP 2008 EUS guidelines

Ann Emerg Med. 2009;53:550-570

急救時超音波的角色為何 ?

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休克評估時超音波的角色為何 ?

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超音波下的變化有何不同 ?

• Hypovolemic shock

• Cardiogenic shock

• Obstructive shock

• Distributive shock

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Goal of focused cardiac US in ED

• Assessment for the presence of pericardial effusion

• Assessment of global cardiac systolic function

• Identification of marked right ventricular and left ventricular enlargement

• Intravascular volume assessment

• Guidance of pericardiocentesis

• Confirmation of transvenous pacing wire placement

18 J Am Soc Echocardiogr 2010;23:1225-30

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Must-See for EPs

Bedside echocardiography: common views

Breitkreutz, Y et al. Crit Care Med 2007;35:S235-S249

2012/1/9 20 2012/1/9 20

CAUSE

• Cardiac Arrest Ultra-Sound Examination

– For non-arrhythmogenic cardiac arrest

– No or minimal interruption of CPR

Resuscitation 2007

2012/1/9 21 2012/1/9 21

CAUSE for Cardiac Arrest

• Severe hypovolemia

• Tension pneumothorax

• Cardiac tamponade

• Massive pulmonary embolism

2012/1/9 22 2012/1/9 22

Apical Four Chamber View

2012/1/9 23 2012/1/9 23

Pneumothorax

2012/1/9 24 2012/1/9 24

CAUSE for Resuscitation

2012/1/9 25 2012/1/9 25

Focused Echocardiographic Evaluation in

Resuscitation (FEER) Management

Breitkreutz, R et al. Crit Care Med 2007;35:S150-S162

2012/1/9 26 2012/1/9 26

FEER in Ten Steps

Breitkreutz, R et al. Crit Care Med 2007;35:S150-S162

FAST

Focused

Assessment with

Sonography for

Trauma

Focused Abdominal

Sonography in Trauma

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UHP Ultrasound Protocol (Undifferentiated Hypotensive Patient)

1. Free intraperitoneal fluid evaluation

2. Focused cardiac examination

3. Focused abdominal aorta

evaluation

Am J Emerg Med 2001

3 Scanning of UHP protocol

Am J Emerg Med 2001

Goal-directed US for nontraumatic

hypotension in ED

• 1. Subcostal view

– Cardiac tamponade

• 2. Inferior vena cava (IVC) view: Collapsibility 50%

– Intravascular volume status

• 3. Parasternal long cardiac view

– LV function and pericardial effusion

• 4. Apical four-chamber cardiac view

– Ventricular size and LV function

• 5. Hepatorenal recess view

– Free intraperitoneal fluid

• 6. The pelvis and retrovesical view

– Free intraperitoneal fluid

• 7. Abdominal aorta view

– Any diameter >3 cm CCM 2004

SBP <90

Shock index >1

One s/s of shock

Diagnosis accuracy

80% vs 50%

CCM 2004

Abdominal and Cardiac Evaluation

with Sonography in Shock (ACES)

protocol

EMJ. 2009;26;87-91

ACES protocol

EMJ. 2009;26;87-91

IVC & RAP

EMJ. 2009;26;87-91

EMJ. 2009;26;87-91

The RUSH Exam Rapid Ultrasound in SHock

in the Evaluation of the Critically Ill

(危急重症患者休克時快速超音波評估)

Step 1: The pump (動力 = 心臟)

Step 2: The tank (容積 = 血容量)

Step 3: The pipes (管路 = 動靜脈)

Emerg Med Clin N Am 28 (2010) 29–56 36

RUSH 步驟 1: 評估動力(心臟)

A. 胸骨旁介面

– 長/短軸

B. 劍突下介面

C. 心尖端介面

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RUSH 步驟 1: 評估動力(心臟)

• ‘‘心臟外圍積液’’

– evaluation of the pericardium

• ‘‘心臟收縮狀態’’

– determination of global left

ventricular function

• ‘‘心臟受迫狀態’’

– assessment of right ventricular

strain

Emerg Med Clin N Am 28 (2010) 29–56 38

RUSH 步驟 2: 評估容積 (血容量)

A. 下腔靜脈長軸

B. 外傷超音波/右上介面

– 含肋膜介面

C. 外傷超音波/左上介面

– 含肋膜介面

D. 外傷超音波/骨盆介面

E. 氣胸/ 肺水腫

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RUSH 步驟 2: 評估容積 (血容量)

• ‘‘容積量評估’’

– 下腔靜脈/頸靜脈的大小和隨呼吸之變化

• ‘‘漏出的液體’’

– 外傷超音波加肋膜掃描

• ‘‘容積受壓迫’’

– 氣胸

• ‘‘容積過多’’

– 肺水腫

Emerg Med Clin N Am 28 (2010) 29–56 40

RUSH 步驟 3: 評估管路 (動靜脈)

A. 胸骨上掃描主動脈

B. 胸骨旁主動脈

C. 上腹部主動脈

D. 臍部上主動脈

E. 股部深部靜脈

F. 膕部深部靜脈

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RUSH 步驟 3: 評估管路 (動靜脈)

• ‘‘管路破裂’’

– 主動脈瘤和主動脈剝離

• ‘‘管路阻塞’’

– 深部靜脈栓塞

Emerg Med Clin N Am 28 (2010) 29–56 42

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Cardiac arrest & Shock

Ann Emerg Med. 2009;53:550-570

謝謝聆聽

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