Slides from Castlefest 2013

1. Cardiac Ultrasound
Dr Cliff Reid Greater Sydney Area HEMS
Ambulance Service New South Wales

5. HYPOXAEMIA
HYPOVOLAEMIA
HYPER/HYPOKALAEMIA
HYPOTHERMIA
TENSION PNEUMOTHORAX
TAMPONADE
TOXIC / METABOLIC /
THROMBOSIS - PULMONARY /
CORONARY

6. PEA / Hypotension
Volume Obstruction Pump
Tension
pneumothorax
Tamponade
Pulmonary
embolism

12. Probe type
Probe orientation
ECG
Patient position
Modes
Just FAST in the CHEST?

13. Echo%Modes
2D ‘B’ mode
M mode
Doppler

14. Echo%Modes
2D ‘B’ mode
M mode
Doppler

15. Echo%Modes
2D ‘B’ mode
M mode
Doppler

17. PLAX PSAX
A4C
SC4C✓

18. Parasternal%Long%Axis

19. Parasternal%Long%Axis
Anima6on%from%Yale%University%Atlas%of%Echocardiography

22. Parasternal%Long%Axis
Image credit: CC Patrick J. Lynch and C. Carl Jaffe, Yale University, 2006.

24. Parasternal%Short%Axis
Anima6on%from%Yale%University%Atlas%of%Echocardiography

25. Parasternal%short%axis
Image credit: CC Patrick J. Lynch and C. Carl Jaffe, Yale University, 2006.

26. Parasternal%short%axis
A
I
S
L

27. 27

28. 28

29. 29

32. Anima6on%from%Yale%University%Atlas%of%Echocardiography
Apical%4%chamber

33. Apical%4%chamber
Image credit: CC Patrick J. Lynch and C. Carl Jaffe, Yale University, 2006.

34. Image courtesy of MikeMallinsNightsOut.com

35. Apical%4%chamber

37. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvisMale age 40
Dyspnea
Hypotension

38. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
Male age 40 SOB Hypotension
Increasing
breathlessness over
two weeks
Previously well
Quiet heart sounds,
BP 85/62, JVP 6cm

39. Cri6cal%Care%Ultrasound
Emergency%Medicine%Spring%Conference%2007
Normal Patient

40. Normal Patient

41. Parasternal short axis

42. Anima6on%from%Yale%University%Atlas%of%Echocardiography
Subcostal

43. Subcostal
Image credit: CC Patrick J. Lynch and C. Carl Jaffe, Yale University, 2006.

44. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
Male 70s
Found on floor
Hypotension
Hypothermia

45. Hypothermia, hypotension

49. Scanning the IVC
‘Volume Assessment’

51. You will see charts like this*
IVC$Size$(cm)
Changes$with$
respira6on$or$“sniff”
Es6mated$mean$
CVP$(mmHg)
Small%<%1.5 Collapse 0L5
Normal%1.5%–%2.5 by%≥%50% 5%–%10
Normal%1.5%–%2.5 by%≤%50% 10%–%15
Dilated%>%2.5 by%<%50% >%15
*usually unreferenced
BOLLOCKS

52. No-one cares what the CVP is
CVP vs Blood volume in 1500 measurements in 188 ICU patients
Chest. 2008 Jul;134(1):172-8.
Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares.

53. “Only a
Window Licker
uses CVP to make
clinical decisions
regarding fluid
management.”
- Someone in Australia

54. TheVolume Question
Does this patient have
a fluid responsive
cardiac output?

55. So what does the IVC tell us?
How much a change in pressure changes
the volume (=compliance)
How stretched the vessel is
(volume in the IVC, not the body)
AND

56. Pressure
Volume
IVC compliance

57. Pressure
Volume
IVC compliance
Small%IVC%collapse%when%
volume%high
respiratory%change%in%
pleural%pressure%
transmiVed%to%IVC

58. IVC compliance
Volume
Large%IVC%
collapse%when%
volume%low
Pressurerespiratory%change%in%
pleural%pressure%
transmiVed%to%IVC

61. CLINICAL assessment
HEART
Do NOT interpret in isolation
LUNGS

63. Affected by Sampling Location
Acad Emerg Med. 2010 Jan;17(1):96-9
Inferior vena cava percentage collapse during respiration is affected by the sampling location: an ultrasound study in healthy volunteers.
HepaticVein
2 cm caudal
to hepatic
vein inlet

64. BIGGER SMALLER
Circulatory obstruction with high RAP
High intraabdominal pressure
Right lateral position
Athletes
Supine position Left lateral position
Tamponade
Pulmonary embolism
Tension pneumothorax
Hypovolaemia
Heart failure
Volume overload
Positive pressure ventilation

66. 66

67. 67

68. 68

71. 71

74. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
Female 30s
Hypotension
Dyspnea

79. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
Male 49
Hypoxia++
Normotensive

82. Image Courtesy of Dr Tim Rogerson FCEM

83. Image Courtesy of Dr Tim Rogerson FCEM

84. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvisElderly M
Dyspnea
Hypotension

85. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis

86. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis

87. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis

88. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis

89. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis

90. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvisMale 50s
Dyspnea
Hypoxic

91. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis

92. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis

93. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis

94. post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis
post ovarian cystectomy 24 hrs +FAST with clots in pelvis

95. PNEUMOTHORAX
PUMP FAILURE
PLEURAL FLUID
PERITONEAL FLUID
PERICARDIAL FLUID
MASSIVE PE
OBSTRUCTION
PUMP
VOLUME

96. mail@cliffreid.comhttp://resus.me/castlefest