echocardiographic approach for shock...winfocus’**critical care echocardiography!...

!WINFOCUS’ BASIC ECHO (WBE)

ECHOCARDIOGRAPHIC APPROACH FOR SHOCK

Achikam Oren-Grinberg, MD, MS

Assistant Professor in Anaesthesia Harvard Medical School

Director of Critical Care Echocardiography Department of Anesthesia

Critical Care and Pain Medicine Beth Israel Deaconess Medical Center

Boston

!BASIC QUESTIONS

• Is it tamponade?

• Is it obvious LV or RV systolic dysfunction?

• Are there signs of pulmonary embolism?

• Is it empty or full?

• Is this septic shock?

• Am I full of air....?

TTE SUBCOSTAL/

APICAL

Pericardial effusion

Severely hypokinetic

Severely enlarged

akinetic RV

Small hyperdynamic LV, collapsed

Hypercontractile LV

Tamponade Pump failure Pulmonary embolism

Hypovolemia Sepsis

No sliding sign Stratosphere

Pneumothorax

ULTRASOUND SHOCK ALGORITHM

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

ULTRASOUND SHOCK ALGORITHM

!PERICARDIAL EFFUSION

• Echo-free space surrounding the heart

• Small (<100 ml): posteriorly only

• Medium (100-500 ml): posterior, lateral, apical, anterior

• Large (>500 ml): > 2 cm circumferentially

!PERICARDIAL EFFUSION

!FINDINGS OF TAMPONADE

• Increased pericardial pressure ➔ chamber collapse

• Sequence of chamber collapse: - RA during systole (RA diastole!!) - RV during diastole - LA during systole (RA diastole!!) - LV during diastole (late)

• IVC Plethora

• Respiratory variation with transmitral flow

!TAMPONADE

The concept to convey here is that with tachycardia` it is impossible to appreciate which chamber collapses in relation to the cardiac cycle. The solution is slowing down the clip or stopping altogether in order to appreciate the relationship between chamber collapse and cardiac cycle. !Note to speaker: it is possible to actually stop the clip during the presentation and move it manually to follow the chamber collapse in relation to the cardiac cycle

!TAMPONADE

!IVC PLETHORA

!PERICARDIAL EFFUSION MEASUREMENT

The point to make in this slide is that measurement of the effusion should be of the largest pocket and in diastole.

!TRANSMITRAL DOPPLER FLOW

This slide just reminds the students about how to obtain the transmitral inflow using pulse wave Doppler. This is just for a brief explanation of the technique. The next slide shows an actual measurement of transmitral inflow from a real patient with tamponade

MV: > 25%

The concept to convey in this slide is the significant variation with respiration. Important to re-emphasize the cut off of 25% change in the mitral valve inflow and 40% in the tricuspid inflow measurement.

!THERAPY

• Pericardiocentesis

The message of this slide is the therapy of tamponade: pericardiocentesis. In this example, once the catheter is placed in the pericardium, saline is injected to verify catheter position before draining the effusion

!THERAPY

• Pericardiocentesis

The message of this slide is the therapy of tamponade: pericardiocentesis. In this example, once the catheter is placed in the pericardium, saline is injected to verify catheter position before draining the effusion

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

ECHO SHOCK ALGORITHM

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

!APPROACH TO “PUMP FAILURE”

Global

Severity - Mild - Moderate - Severe

Size - Normal - Dilated

• Cardiomyophathy

The concept to emphasize in this slide is the approach to assessment of “pump failure”. In a very simplistic way, it is important to assess separately and sequentially the left and then the right ventricles for global and then regional wall motion abnormalities. !Both global and RWMA should then be qualified into the degree of severity. It is easy to divide them into three major groups -- mild, moderate or severe dysfunction

!“PUMP FAILURE” CAUSES

• Cardiomyopathy

• Sepsis

• Ischemia/Acute coronary syndrome

• Myocarditis

• Cardiac contusion (RV)

This is just a partial list of causes of left ventricular systolic dysfunction.

!ABNORMAL FUNCTION

• Qualitative assessment (eyeballing approach) - Using 2D modality

• Global vs. Regional wall motion abnormalities (Can have both!)

• Ejection fraction - Normal - Moderately depressed - Severely depressed

• Cardiac output calculation

!NORMAL LV SYSTOLIC FUNCTION

In order to appreciate left ventricular systolic dysfunction one must first know what is normal function. Here is an example of four clips of normal left ventricular systolic function

!NORMAL LV SYSTOLIC FUNCTION

In order to appreciate left ventricular systolic dysfunction one must first know what is normal function. Here is an example of four clips of normal left ventricular systolic function

!GLOBAL HYPOKINESIS

!RWMA: FOCAL AKINESIS

It is worth to emphasize that this is a grainy clip due to too much gain, but even with this suboptimal clip the apex is akinetic and even aneurysmal

!RWMA: FOCAL AKINESIS

It is worth to emphasize that this is a grainy clip due to too much gain, but even with this suboptimal clip the apex is akinetic and even aneurysmal

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

!APPROACH TO “PUMP FAILURE”

RVRWMA

Global

Severity - Mild - Moderate - Severe

Size - Normal - Dilated

• Mild • Moderate • Severe

The concept to emphasize in this slide is the approach to assessment of “pump failure”. In a very simplistic way, it is important to assess separately and sequentially the left and then the right ventricles for global and then regional wall motion abnormalities. !Both global and RWMA should then be qualified into the degree of severity. It is easy to divide them into three major groups -- mild, moderate or severe dysfunction

!PULMONARY EMBOLISM

• Significant PE leading to hemodynamic instability will lead to signs of RV pressure overload - RV dilatation - RV free wall hypokinesis - Paradoxical septal movement (pressure overload)

• May see clot in transit (if lucky....)

!NORMAL RV FUNCTION

RV#func(on#assessment#mostly#

qualita(ve#

RV#free#wall#mo(on#towards#

the#apex#

Look#for#thickening#

Look#at#Tricuspid#

annular#mo(on#

!NORMAL RV FUNCTION

RV#func(on#assessment#mostly#

qualita(ve#

RV#free#wall#mo(on#towards#

the#apex#

Look#for#thickening#

Look#at#Tricuspid#

annular#mo(on#

!NORMAL RV SIZE & FUNCTION

Normal RV/LV size: < 0.6 RV/LV = 1: mod RV dilatation

RV/LV > 1: significant RV dilatation

!ABNORMAL RV SIZE AND FUNCTION

!McCONNELL’S SIGN

• Akinesia/hypokinesia of the mid-free wall

• Apical sparring (normal apical function)

• “Bye-bye sign”

• Original publication: 77% sensitive, 94% specific

• Not as specific as initially published

!CLOT IN TRANSIT

!THERAPY

• Echo is NOT a diagnostic modality for pulmonary embolism

However.....

• With high pre-test probability and no access to CTA, can be used to guide diagnosis - Heparin - tPA - Surgical embolectomy - Catheter thrombectomy

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

2D clues of hypovolemic shock ‣ Small LV & RV diameter in systole and diastole ‣ Hypercontractile RV & LV ‣ Small and collapsing IVC

HYPOVOLEMIC SHOCK

The point to convey in this slide is that echo is not a good modality to assess fluid status. But it can be used to demonstrate hypovolemic shock -- basically when the “tank is empty”, the patient suffers from severe hypovolemic shock

!2D SIGNS OF HYPOVOLEMIC SHOCK

This is an example of a patient who was in septic shock and a PAC used to assess hemodynamic demonstrated “bi-ventricular systolic dysfunction”: both CVP and PAOP were very high (> 20 mmHg). The team’s plan was to start inotropic support, however, an echocardiogram clearly demonstrated severe hypovolemia as seen in these clips. The other two clips show the same heart 24 hours after, and after appropriate fluid resuscitation. !The problem with the PAC was partially technical - it was placed in the left subclavian position and it appeared as if it was compressed by the clavicle.

!THERAPY

Therapy is easy once the diagnosis is made - either aggressive fluid therapy or blood depending on the etiology

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

!MANIFESTATION OF SEPTIC SHOCK

• Hypercontractile state (hyperdynamic)

• Hypocontractile state (“pump failure”) - Global LV (and sometimes RV) hypokinesis

!MANIFESTATION OF SEPTIC SHOCK

• Hypercontractile state (hyperdynamic)

• Hypocontractile state (“pump failure”) - Global LV (and sometimes RV) hypokinesis

!Hyperdynamic ➙ Hypodynamic

!LV DYSFUNCTION IN SEPSIS

This is an example of a patient in septic shock and septic cardiomyopathy, which resolved after the resolution of sepsis

!LV DYSFUNCTION IN SEPSIS

This is an example of a patient in septic shock and septic cardiomyopathy, which resolved after the resolution of sepsis

HYPOVOLEMIA

Low ESA

Low EDA

Normal EDA

VASODILATION

HYPOVOLEMIA VS. VASODILATATION

This slide explains the difference between severe hypovolemia and vasodilatory shock. While in both cases end-systolic area will be small, in vasodilatory state end-diastolic area will be either normal or only slightly reduced. In hypovolemic shock end-diastolic area will be much reduced.

HYPOVOLEMIA

Low ESA

Low EDA

Normal EDA

VASODILATION

HYPOVOLEMIA VS. VASODILATATION

This slide explains the difference between severe hypovolemia and vasodilatory shock. While in both cases end-systolic area will be small, in vasodilatory state end-diastolic area will be either normal or only slightly reduced. In hypovolemic shock end-diastolic area will be much reduced.

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

!PNEUMOTHORAX

• Change to high frequency probe

• Interrogate bilateral anterior intercostal spaces

• Interrogate all spaces, not just one

• Look for lung sliding sign (live 2D mode)

• Verify with M-mode - Stratosphere sign (bar code sign): Normal - Seashore sign: Abnormal (± pneumothorax)

!LUNG POINT

!THERAPY

Therapy is easy once the diagnosis is made....

TTE SUBCOSTAL/

APICAL

Severely enlarged

akinetic RV

Hypercontractile LV

Hypovolemia Sepsis

Pneumothorax

echocardiographic approach for shock...winfocus’**critical care echocardiography!...

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