Introduction to critical care US

SAH & RNSH 2011

Critical Care Ultrasound Course

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 Goals of today's course

• Understand critical care ultrasound

• Understand its limitations (& your own)
• Learn the basics of lung, IVC and cardiac sonography
• Learn the arrest / shock / breathless algorithms
• Perform a 3-minute screen
 A real case
(My road to Damascus)

• shocked 30 yr old male

• breathless & severe chest pain
• mildly febrile, heart racing
• unresponsive to O2 / fluid / antibiotics
• Recovering from a common cold
• no RFs for the usuals
• getting worse in front of us
 Initial investigations

• CXR clear
• ECG non specific
• ABG markedly abnormal gas exchange
Atypical pneumonia?
Or a PE?
 OK, let’s get a scan.

• Too unstable for CT / VQ scan

• Cardiology: ‘too busy’
• Radiology: ‘we don’t do echo’
#*%* !!!
 Get out the ED US machine!

• Lungs
• IVC
• Heart
• Leg veins
Lungs clear
Non-collapsing IVC
RV > LV
DVT
 Results

• Lungs clear
• Distended IVC
• High pressure dilated RV > LV
• DVT
• Diagnosis?
 Massive PE

• Working diagnosis: massive PE (not atypical pneumonia)

• Treatment: ED thrombolysis
• Rapid improvement
Essential features of any bedside test
in critical care

• Improves accuracy of diagnosis in the critically ill

(prehospital, ED, ICU)
• Guides treatment / resuscitation / procedures
• Rapid
• Simple
• Repeatable
 BSL
ECG
O2 Sats
Bedside Critical Care US (CCUS)
 Why?

• A simple 3-minute ultrasound can assist in diagnosis and

resuscitation
• It may not give you the final diagnosis
• But it buys you the time to perform a more detailed
assessment once stabilised
• EG a focused TTE
• EG a CT scan
 What is critical care US?

• A rapid, patient-focused bedside US scan

• Initial rapid scan: lungs / IVC / heart (curved probe) / other
areas as appropriate
• Then, after initial resuscitation, a more rigorous look at
specific areas as indicated:
• Heart / Lungs / Abdomen / Leg veins
 Why isn't focused TTE enough?

Focused TTE Rapid CCUS screen

1. Just looks at heart 1. Heart / lung / IVC / veins
2. Cardiac probe / preset 2. Curved probe / abdo preset
3. Difficult windows 3. Simple windows
4. Slow learning curve 4. Rapid learning curve
5. Takes several minutes 5. Takes 3 minutes
6. No cardiac windows = no 6. Works even if you can't see the
information heart / IVC
7. Adapted from formal TTE 7. Purpose-built & validated for
critical care
Does the screen really take 3 minutes?
 Why isn't focused TTE enough?

• Cardiac sonographer: 'the DDx between pericardial & left

pleural fluid can be subtle'
Duh! Just look at the left thorax
This is why focused TTE isn’t enough

• Cardiologists look after the heart → echocardiography just

looks at the heart

• Critical care doctors look after the entire patient → so our

US scan should look at the patient, not just an organ
Whole-body ultrasound
 Current standard of critical care
ultrasound

LUNG
IVC
HEART
+other regions as
appropriate
 An important note

• Cardiologist: 'Why do you want an urgent echo? Echo can't

rule out a PE'

• ED physician: 'But this will rule out a massive PE'

If it's a PE making the patient critically unwell, then it won't be a

small one.
Top tip: bloody sick = bloody
obvious

We're not looking for small pneumothorax or

mild CCF
('rule-in', not 'rule-out')

If the patient is unstable, the US signs

should be obvious
 What this isn't

A formal echocardiogram The holy grail

• It doesn't use M-mode or
Doppler
• It doesn't look for subtle
disease
• It includes other windows &
other organs to synthesize
the answer
• It is not validated in those
with minor degrees of
illness (eg mild CCF)
• It will sometimes be wrong
in the critically ill
• It's just another tool
 Limitations of critical care US

• Algorithm: only validated in critically unwell patients

• Patient: suboptimal position & still being resuscitated!
• Time (none!)
• Sonographer
• Image acquisition
• Image interpretation
 So: the golden rules
1. 'Resus-only': Patient must be critically unwell: shocked / breathless /
peri-arrest. That's because the US signs of some of these diseases
are only reliably present if severe eg massive PE, severe
pneumonia. If formal studies are needed after resus, get them.

2. Clinical context is paramount. Make a differential diagnosis list

before you switch on the machine. All data must be considered (eg
FBC with Hb = 4).

3. Only ask questions that you can answer. Leave the fancy stuff (eg
valve disease) to others.

4. Repeat scans are crucial during resuscitation & each time clinical
picture changes.
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 Golden rules
5. 90% = 100%: Every test has its limitations. In a periarrest patient, no
study will be 100% accurate. If this bothers you, don't practise
critical care.

RNSH respiratory physician: 'Would you really thrombolyse a critically

ill patient with suspected PE on the basis of bedside US?'

ED physician answer: 'I spent years doing just that without the benefit
of US. Anything that improves my accuracy suits me fine.'

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 Golden rules

6. When in doubt, be a doctor. You were a clinician before you were a

sonographer. If the clinical picture & scan findings don’t agree, believe the
clinical picture.

‘What would I diagnose if I didn’t have an US machine?’

 The golden rules
1. 'Resus-only'

2. Clinical context is paramount.

3. Only ask questions that you can answer.

4. Repeat scans are crucial.

5. 90% = 100%

6. When in doubt, be a doctor.

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7. A fool with a stethoscope will be a fool with an
ultrasound
 Critical care US

• It’s not the Holy Grail

• Just another tool
• Rapid
• Safe
• Accurate
• Not difficult
 Thanks to
Daniel Lichtenstein
Paul Atkinson
Conn Russell
Rob Reardon
Vicki Noble
Russell McLaughlin (for rule #7)

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 References
 Blaivas M, Lyon M, Duggal S. A Prospective Comparison of Supine Chest Radiography and Bedside Ultrasound for the Diagnosis of Traumatic Pneumothorax.
Acad Emerg Med 2005; 12(9): 844-9.

• Jones AE, Craddock PA, Tayal VS, Kline JA: Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with
nontraumatic symptomatic undifferentiated hypotension. Shock 24:513-7,2005.

• Kaul S, Stratienko AA, Pollock SG, Marieb MA, Keller MW, Sabia PJ: Value of two-dimensional echocardiography for determining the basis of hemodynamic
compromise in critically ill patients: a prospective study. J Am Soc Echocardiogr 7:598-606,1994.

• Kohzaki S et al. The aurora sign: an ultrasonographic sign suggesting parenchymal lung disease. The British Journal of Radiology 76 (2003), 437–443

 Lichtenstein D. Whole Body Ultrasonography in the Critically Ill. Springer, 2nd ed. !st published 1992.

 Lichtenstein D, Meziere G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care med

1998; 24(12): 1331-4.

• Lim et al. Ring-down artifacts posterior to the right hemidiaphragm on abdominal sonography: sign of pulmonary parenchymal abnormalities. J Ultrasound

Med.1999; 18: 403-410

• Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA: Determination of left ventricular function by emergency physician echocardiography of
hypotensive patients. Acad Emerg Med 9:186-93,2002.

• Plummer D, Heegaard W, Dries D, Reardon R, Pippert G, Frascone RJ: Ultrasound in HEMS: its role in differentiating shock states. Air Med J 22:33-6,2003.

• 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 10:973-7,2003.

• Reissig A, Kroegel C. Transthoracic Sonography of Diffuse Parenchymal Lung Disease: The Role of comet-tail artefacts. J Ultrasound Med 2003; 22(2): 173 -
80.

• Rose JS, Bair AE, Mandavia D, Kinser DJ: The UHP ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated
hypotensive patient. The American journal of emergency medicine 19:299-302,2001.

• WINFOCUS WORKING GROUP 4. Shock state discussion paper, 3rd world congress on US in EM and critical care, Paris 2007

• Yanagawa Y, Nishi K, Sakamoto T, Okada Y: Early diagnosis of hypovolemic shock by sonographic measurement of inferior vena cava in trauma patients. The
Journal of trauma 58:825-9,2005.

• http://www.uptodate.com/contents/thoracic-ultrasound-indications-advantages-and-
technique?source=preview&selectedTitle=4%7E150&anchor=H1492303#H1492303
 PS
Even if I hand't performed an US, I probably
still would’ve thrombolysed him.