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 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

ACEP 2008 EUS guidelines Ann Emerg Med. 2009;53:550-570

急救時超音波的角色為何 ?

休克評估時超音波的角色為何 ?

超音波下的變化有何不同 ? Hypovolemic shock Cardiogenic shock Obstructive shock Distributive shock

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 J Am Soc Echocardiogr 2010;23:1225-30

Must-See for EPs Bedside echocardiography: common views 19 Breitkreutz, Y et al. Crit Care Med 2007;35:S235-S249

CAUSE Cardiac Arrest Ultra-Sound Examination For non-arrhythmogenic cardiac arrest No or minimal interruption of CPR 2018/11/11 20 2018/11/11 Resuscitation 2007

CAUSE for Cardiac Arrest Severe hypovolemia Tension pneumothorax Cardiac tamponade Massive pulmonary embolism 2018/11/11 21 2018/11/11

Apical Four Chamber View 2018/11/11 22 2018/11/11

Pneumothorax 2018/11/11 23 2018/11/11

CAUSE for Resuscitation 2018/11/11 24 2018/11/11

Focused Echocardiographic Evaluation in Resuscitation (FEER) Management 2018/11/11 25 2018/11/11 Breitkreutz, R et al. Crit Care Med 2007;35:S150-S162

FEER in Ten Steps 2018/11/11 26 2018/11/11 Breitkreutz, R et al. Crit Care Med 2007;35:S150-S162

Focused Abdominal Sonography in Trauma FAST Focused Assessment with Sonography for Trauma

UHP Ultrasound Protocol (Undifferentiated Hypotensive Patient) Free intraperitoneal fluid evaluation Focused cardiac examination 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 7. Abdominal aorta view Any diameter >3 cm 1. Subcostal view: The subcostal region of the abdomen was examined for anechoic collections within the pericardium suggesting tamponade, judged to be present by visual inspection for right ventricular diastolic collapse (4–5). 2. Inferior vena cava (IVC) view: The IVC was examined for diameter and visual estimation of collapsibility to estimate intravascular volume status. A >50% collapse of IVC with inspiration was considered abnormal suggesting low intravascular volume, and <50% collapse of IVC with inspiration was considered normal suggesting normal intravascular volume (6–7). 3. Parasternal long cardiac view: The left parasternal chest was examined for visual estimation of qualitative left ventricular function and pericardial effusion. Left ventricular function was judged by visual inspection of gross wall contraction and wall thickening during systole and diastole (2, 8). 4. Apical four-chamber cardiac view: The apex of the heart was examined in the transverse plane for visual estimation of relative ventricular size and qualitative function (2, 8). 5. Hepatorenal recess view: The space between the liver and right kidney was examined for anechoic collections in a sweeping motion using both in the coronal and transverse planes to survey for free intraperitoneal fluid (9, 10). 6. The pelvis and retrovesical area were examined in both the sagittal and transverse planes for the presence of anechoic fluid collections (9, 10). 7. Abdominal aorta view: The abdomen was examined in the transverse and sagittal planes for evidence of aneurysm of the proximal and distal aorta (any diameter >3 cm) (11, 12). 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

RUSH 步驟 1: 評估動力(心臟) 胸骨旁介面 長/短軸 劍突下介面 心尖端介面

RUSH 步驟 1: 評估動力(心臟) ‘‘心臟外圍積液’’ ‘‘心臟收縮狀態’’ ‘‘心臟受迫狀態’’ 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

RUSH 步驟 2: 評估容積 (血容量) 下腔靜脈長軸 外傷超音波/右上介面 外傷超音波/左上介面 外傷超音波/骨盆介面 氣胸/ 肺水腫 含肋膜介面 外傷超音波/左上介面 外傷超音波/骨盆介面 氣胸/ 肺水腫

RUSH 步驟 2: 評估容積 (血容量) ‘‘容積量評估’’ ‘‘漏出的液體’’ ‘‘容積受壓迫’’ ‘‘容積過多’’ 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

RUSH 步驟 3: 評估管路 (動靜脈) 胸骨上掃描主動脈 胸骨旁主動脈 上腹部主動脈 臍部上主動脈 股部深部靜脈 膕部深部靜脈

RUSH 步驟 3: 評估管路 (動靜脈) ‘‘管路破裂’’ ‘‘管路阻塞’’ 主動脈瘤和主動脈剝離 深部靜脈栓塞 Emerg Med Clin N Am 28 (2010) 29–56

Cardiac arrest & Shock Ann Emerg Med. 2009;53:550-570

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