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The Pros examine

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  1. The ACES scan Ultrasound in hypotension Richard Kendall Paul Atkinson emergencyultrasound.org.uk

  2. TheACES scan • Abdominal (and) • Cardiac • Evaluation (with sonography in) • Shock emergencyultrasound.org.uk

  3. The ACES scan • Extension of more established emergency medicine uses of ultrasound • Abdominal component • Cardiac component • (Peripheral component) emergencyultrasound.org.uk

  4. Case 1 • ‘Red call’ • Elderly female – collapsed and absent radial pulse • Arrives – peri-arrest • Groaning • Initial resuscitation • ACES scan emergencyultrasound.org.uk

  5. Case 1 • Huge AAA, tender • Terminal care instituted emergencyultrasound.org.uk

  6. Case 2 • ‘Red call’ • 62 year old man • Hypotension, epigastric pain • Unwell ?AAA • 10 minutes emergencyultrasound.org.uk

  7. Case 2 • BP 74/54, Pulse 110, clammy • Initial resuscitation underway • ACES scan emergencyultrasound.org.uk

  8. No AAA Abdomen emergencyultrasound.org.uk

  9. No free fluid Abdomen emergencyultrasound.org.uk

  10. Abdomen - IVC • Slight collapse on inspiration emergencyultrasound.org.uk

  11. Cardiac - subcostal • No pericardial effusion • Hyperdynamic • Not small • RV not dilated emergencyultrasound.org.uk

  12. CXR • Fluid challenge • IV antibiotics • IJ line (us control) • ICU emergencyultrasound.org.uk

  13. ACES scan • Aim is to help identify the likely cause of hypotension emergencyultrasound.org.uk

  14. Causes of Hypotension • Hypovolaemia • Obstructive (tamponade) • Obstructive (PE) • Cardiogenic • Distributive (septic) emergencyultrasound.org.uk

  15. Hypovolaemia Two aims of ACES scan:- • To establish existence of hypovolaemic state • IVC • ‘collapse index’ • Cardiac • Small chamber size ‘small heart’ • Aggressive wall motion ‘hyperdynamic’ • To identify possible causes • AAA • Free fluid (haemoperitoneum) emergencyultrasound.org.uk

  16. Tamponade Aims of ACES scan to:- • Identify pericardial effusion • Collapse RA/RV during diastole = tamponade emergencyultrasound.org.uk

  17. PE ACES scan aims to identify:- • RV dilatation • RV hypokinesis • Paradoxical septal motion • IVC distension • (Peripheral views for DVT) emergencyultrasound.org.uk

  18. Cardiogenic ACES scan aims to identify gross abnormalities of cardiac:- • Size • Normal • Small • Dilated • Motion • Normal • Hyperdynamic • Hypodynamic Hypodynamic myocardium = cardiogenic emergencyultrasound.org.uk

  19. Sepsis ACES scan aims to identify:- • Hyperdynamic left ventricular function • Hyperdynamic heart has sensitivity of 33% and a specificity of 94% for sepsis Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with non traumatic symptomatic undifferentiated hypotension Jones A et al Shock 2005 Dec;24(6) :513-7 emergencyultrasound.org.uk

  20. ACES scan - 6 windows • Cardiac • IVC • Aorta • RUQ • LUQ • Pelvis emergencyultrasound.org.uk

  21. IVC and collapse index • Relationship between IVC pressure and RA pressure • Identify IVC • Measure in inspiration and expiration • M mode • Calculate ‘collapse index’ emergencyultrasound.org.uk

  22. IVC and collapse index emergencyultrasound.org.uk

  23. Collapse Index • Inspiration – IVC collapses slightly • Expiration – IVC maximal diameter emergencyultrasound.org.uk

  24. Collapse Index (CI) Max diameter – Min diameter CI = x 100% Max diameter Maximum diameter - expiration Minimum diameter - inspiration emergencyultrasound.org.uk

  25. Collapse Index • CI > 50% = RA pressure < 10mmHg • CI < 50% = RA pressure > 10mmHg Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava Kircher BJ et al Am J Cardiol 1990 Aug 15;66(4):493-6 emergencyultrasound.org.uk

  26. ACES scan - subcostal • Pericardial effusion • Gross assessment of cardiac wall motion • Normal • Hypodynamic • Hyperdynamic • Gross assessment of cardiac chamber size emergencyultrasound.org.uk

  27. ACES scan – additional views • Thoracic views – parasternal, apical • Augment subcostal view • (Peripheral views – DVT) emergencyultrasound.org.uk

  28. Summary ACES scan emergencyultrasound.org.uk