Bedside ultrasound as adjunct to

Shock patient
Suthaporn Lumlertgul M.D.
Emergency unit, King Chulalongkorn Hospital
WINFOCUS Thailand director

Shock
Question 1: Does the patient need volume

Hypovolemic Shock
Need Volume

Distributive(Septic) Shock
Cardiogenic Shock
Don't need Volume

Obstructive Shock

Shock

Hypovolemic Shock

Need Volume

What cause leaking of fluid?

Distributive(Septic) Shock

Need Volume

Does not need Volume

Volume Responsive Shock

Collapse IVC

Hyperdynamic Heart

Source of Bleeding

IVC

HEART

FAST

1. Is there free fluid/blood in the abdomen?

2. Is there fluid/blood in the pericardium?

1. Is there fluid/blood in the thorax?

2. 2. Is there a pneumothorax?

Hepatorenal
recess

Splenorenal
view

1
5

2
3,4

Shock
LV dysfuntion
Cardiogenic Shock

Valve

Obstructive Shock

Tamponade
Pulmonary Embolism
Tension Pneumothorax

Question: Does patient have good

Pumping
Effusion(Pericardial)

Ejection fraction
EYEBALL, EPSS

Equality(Pulmonary embolism)

Shock
LV dysfuntion
Cardiogenic Shock

Valve

Obstructive Shock

Tamponade
Pulmonary Embolism
Tension Pneumothorax

Summary of the major ultrasound protocol for

medical assessment

RUSH - every organ except Gyne

POCUS - every organ except lung effusion
FEEL- Heart
FATE - Heart+ Pleural effusion

Circumferential
compressive
pericardial effusion

Tamponade

PE
RV
IVS
MV
PW

normal M mode from http://

collapse of the RV during diastole.

P
R
IV

}
diastol
ventricular

M
P

A 1 years old male pt, referred in with arrest from 2nd degree
Burn

Circulatory failure
Persistent shock despite initial
therapy

Main Mechanism of shock

Complicated AMI

RWMA, LV dysfunction, RV
involvement, mechanical
complication

Complicated acute coronary

syndrome

Tamponade, acute aortic

regurgitation, LV dysfunction

Massive Pulmonary Embolism

Acute corpulmonale

Cardiac tamponade

Circumferential compressive
pericardial effusion

Does this patient have a bad

pumping(poor EF)?
Does this patient need inotrope?

LV Function
Global hypokinesis = reduced EF

Do not need a number

Normal (>50%)

Decreased (30-50%)

Severely decreased (<30%)

Things to look for

Wall movement--change in ventricular area

Wall thickening

MV anterior valve movement (2-7 mm normal)

Weekes AJ, Zapata RJ, Napolitano A. Symptomatic Hypotension: ED Stabilization and the Emerging Role of Sonography. Emergency Medicine
Practice. Nov 2007, Vol. 9, No. 11.

Compare eyeball(3 grade) to actual measure

LV Function

Weekes AJ, Zapata RJ, Napolitano A. Symptomatic Hypotension: ED Stabilization and the Emerging Role of Sonography. Emergency Medicine
Practice. Nov 2007, Vol. 9, No. 11.

LV Function--Can we do it?

EPs with focused echo training

Performed echo and called it normal,

depressed, or severely depressed.

EPs with 3 hours of echo

training

115 patients

Yes!
We
are
smart!
Blinded cardiologists overread

Overall agreement, 86%

51 hypotensive patients

Agreement between EPs and the

primary cardiologist was 84%
Moore, C. L., G. A. Rose, et al. (2002). "Determination of left ventricular
function by emergency physician echocardiography of hypotensive patients."
Acad Emerg Med 9(3): 186-93.

Randazzo MR, Snoey ER, Levitt MA, Binder K. Accuracy of emergency

physician assessment of left ventricular ejection fraction and central venous
pressure using echocardiography. Acad Emerg Med. 2003 Sep;10(9):973-7.

Inward motion of
the endocardium
Longitudinal motion of
the mitral annulus
Thickening of the
myocardium
Geometry of the ventricle

Mitral Valve Closing= Systolic Phase Implied

Systolic thickening

Mitral Valve Opening = Diastolic Phase Implied

Systolic thickening

Question: Does patient have good

Pumping
Effusion(Pericardial)

Ejection fraction
EYEBALL, EPSS

Equality(Pulmonary embolism)

RV Dysfunction

DVT

ARDS

CHF

Pneumothorax

Pleural effusion

Pleural line

pleural line

A line

X
A line

rib shadow