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Echo Evaluation in Shock
Senior Clinical Fellow, Adult
Intensive Care
Royal Brompton Hospital,
London, UK
Dr. Hatem Solima...
Disclosure
Nothing to disclose
What is shock?
Types of Shock
Echocardiographic assessment of shocked patients
Take Home messages
Resources
Overview
?
Wha...
Shock
A life‐ threatening, generalized form of circulatory failure
associated with inadequate oxygen delivery to the cells...
Clinical Dx
Hypotension (Not always)
Altered mental status
Poor Peripheral Perfusion (Cold clammy skin,  UOP
Cecconi M, De Backer A, Antonelli M, et al. Intensive Care Med. 2014;40:1795–815.
Evidence
Recommended as the modality of ...
Distributive
ObstructiveHypovolaemic
Cardiogenic
Post-MI
Sepsis-induced ! Very important
Shock
Stroke Volume
LV Systolic Function
Valvular Pathology
LV Diastolic Function
Cardiogenic Shock
Well validated
Supplants invasive CO measurements
(LVOT area x LVOT VTI)
VTI = Velocity Time Integral
Stroke Volume
Pearls
The LVOT velocity time integral (VTI) a surrogate for the stroke volume
Normal value >20 cm
Non-alignment of Dopple...
 cardiac index
 RV afterload
How does Mechanical Ventilation ↘ cardiac output?
Cautions
Ejection Fraction
Eyeballing is accurate with
experience
A prognostic marker in chronic
heart failure
effects of ...
Tissue Doppler Imaging
S’ Myocardial systolic velocity
Correlates with LVEF
Cautions
S’  with age
Doesn’t differntiate ac...
Valvular
Acute Chronic
Diastolic Dysfunction
50% of patients with acute heart failure have preserved
ejection fraction
TDI analysis of the mitral...
E/A ratio >2 and E wave deceleration time <120 ms
predict a LAP >20 mmHg
Lateral e′ <10 and medial <7 cm/s are highly sugg...
Diastolic Dysfunction
Lung US for B-lines
Cardiogenic Shock
Other Causes:
Post infarction VSD
Acute aortic dissection with AR
Distributive
Obstructive
Hypovolaemic
Cardiogenic
Shock
Hypovolemic Shock
Assessment of intravascular volume is the beginning in all types of shock
Hypovolemia is severe kissing ...
Measuring the IVC
0.5– 3 cm from the caval– right atrial junction in the subcostal
view
Teboul JL et al. Chest 2001, 119:867–873
Volume Responsiveness
Inferior Vena Cava (IVC) Dispensability (TTE subcostal view...
Respiratory Variations
Collapsibility Index
CI = (Dmax − Dmin )/Dmax ~ 100 %
DI = (Dmax − Dmin )/Dmin
In fully supported on Mechanical Ventilatio...
SVC Collapsibility
Basal After 1500 ml fluids
Pitfalls
Not valid patients receiving partial ventilatory support
Only valid in the extremes
fluid responsiveness is deter...
IVC Collapsibility
Basal After 1500 ml fluids
IVC vs. CVP Guidelines
IVC Pitfalls
Volume Overload Obstructive Shock
Aortic stenosis
RV FailureIntraabdominal Pressure
Status Asthmaticus MR
LV end diastolic area (LVEDA) < 5.5 cm/m2 BSA
(or < 10 cm2)
Distributive
ObstructiveHypovolaemic
Cardiogenic
Shock
Obstructive Shock
Resistance to blood flow through the cardiopulmonary Circulation
Causes:
acute pulmonary embolus
cardiac...
Dilated right chambers
decreased cardiac output
RV/LV area ratio >0.6;
gross dilatation is seen
with a ratio >1.0
Acute PE...
Acute PE
PAcT of 70– 90 ms indicates a pulmonary
artery systolic pressure of >70 mmHg
Mid‐systolic notch also indicates se...
Also in RV infarction
The McConnell’s sign
Non-specific
RV Free wall hypokinesia with preserved apex
When the intra-pericardial pressure exceeds right heart
filling pressure (diastole)
Cardiac Tamponade
Impaired filling of ...
RA systolic collapse for longer than one-third of the
cardiac cycle
Cardiac Tamponade
RV diastolic collapse
Echo Findings
...
Cardiac Tamponade
Echo Findings
Exaggerated respiratory variations of the mitral and tricuspid inflow
(Pulsus Paradoxus)
Cardiac Tamponade
Echo Findings
Size is not a guide to the presence of tamponade.
The opposite of respiratory variations if
positive pressure ventilation
...
Typical with basal septal hypertrophy
Dynamic LVOT Obstruction
close approximation of lateral wall and septum
Echo Finding...
Dynamic LVOT Obstruction
Causes Acute MI in the apical and mid segments
Stress Cardiomyopathy (Takatsubo)
Dobutamine in pa...
Pitfalls
absence of septal hypertrophy in the elderly
Tachycardia, hypovolemia, and inotropes makes critically ill more pr...
Distributive
ObstructiveHypovolaemic
Cardiogenic
Shock
Septic Shock
Heart is either the “Source” or the ”Victim” of the septic process
Left ventricular dilatation
LV, RV Systoli...
Early
Septic Shock
Small & Collapsing IVC
Small LV
LV and RV hyperkinesia
Small RV
A clue to the presence of marked periph...
Late
Septic Shock
Sepsis induced
myocardial suppression
April 2015, www.survivingsepsis.org
6-hour Bundle
Pitfalls
a normal study is not unusual
speckle tracking recently utilized to assess prognosis in such patients
Takutsubo C...
Chang, WT. et al. Intensive Care Med (2015) 41: 1791
LV GLS provides prognostic information as an outcome
predictor for mo...
Echo is the most single useful tool in the diagnosis and Rx of shock
Hyperdynamic LV also is highly specific for sepsis (9...
Resources
EACVI/ACCA recommendation for use of Echo in Acute Cardiac Care
Twitter: #POCUS #SMACC #FOAMEd #FOAMus #FOAMcc
A...
EGLS RUSH FATE
Resources
Thank
You
hatem.soliman@gmail.com
@hatemsoliman
Any suggestions or input? Contact me at:
Echocardiographic Evaluation of Shock States
Echocardiographic Evaluation of Shock States
Echocardiographic Evaluation of Shock States
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Echocardiographic Evaluation of Shock States

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A lecture discussing the role of Echocardiography in the evaluation and management of patients with different types of shock. From cardiogenic to hypovolemic to obstructive and distributive shock. A very useful guide for intensivists, cardiologists and all acute care physicians.

Publicado en: Salud y medicina
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Echocardiographic Evaluation of Shock States

  1. 1. Echo Evaluation in Shock Senior Clinical Fellow, Adult Intensive Care Royal Brompton Hospital, London, UK Dr. Hatem Soliman Aboumarie MBBS, MRCP, MSc, Dip. Cardio. (London), ASCeXAM (USA)
  2. 2. Disclosure Nothing to disclose
  3. 3. What is shock? Types of Shock Echocardiographic assessment of shocked patients Take Home messages Resources Overview ? What is the problem ?
  4. 4. Shock A life‐ threatening, generalized form of circulatory failure associated with inadequate oxygen delivery to the cells Most cases of shock are mixed “Septic and Cardiogenic” “Hypovolemic and Dynamic LVOT obstruction” The majority of shocked patients are readily identified using basic echocardiography (Dx, Rx, Monitoring)
  5. 5. Clinical Dx Hypotension (Not always) Altered mental status Poor Peripheral Perfusion (Cold clammy skin,  UOP
  6. 6. Cecconi M, De Backer A, Antonelli M, et al. Intensive Care Med. 2014;40:1795–815. Evidence Recommended as the modality of first choice in consensus guidelines
  7. 7. Distributive ObstructiveHypovolaemic Cardiogenic Post-MI Sepsis-induced ! Very important Shock
  8. 8. Stroke Volume LV Systolic Function Valvular Pathology LV Diastolic Function Cardiogenic Shock
  9. 9. Well validated Supplants invasive CO measurements (LVOT area x LVOT VTI) VTI = Velocity Time Integral Stroke Volume
  10. 10. Pearls The LVOT velocity time integral (VTI) a surrogate for the stroke volume Normal value >20 cm Non-alignment of Doppler beam: VTI will be underestimated Record the measured LVOT area in the file Average of 5 measurements in AF
  11. 11.  cardiac index  RV afterload How does Mechanical Ventilation ↘ cardiac output?
  12. 12. Cautions Ejection Fraction Eyeballing is accurate with experience A prognostic marker in chronic heart failure effects of blood pressure (afterload), inotropes, and vasopressors  HR, AF may underestimate EF
  13. 13. Tissue Doppler Imaging S’ Myocardial systolic velocity Correlates with LVEF Cautions S’  with age Doesn’t differntiate active contraction from tethering Global Longitudinal Strain identify systolic dysfunction in patients with normal LVEF in oncology and heart failure patients
  14. 14. Valvular Acute Chronic
  15. 15. Diastolic Dysfunction 50% of patients with acute heart failure have preserved ejection fraction TDI analysis of the mitral annulus allows for rapid estimation of left atrial pressure
  16. 16. E/A ratio >2 and E wave deceleration time <120 ms predict a LAP >20 mmHg Lateral e′ <10 and medial <7 cm/s are highly suggestive of diastolic dysfunction and elevated left atrial pressures Average E/e′ of >14 elevated left atrial pressure Pearl E/e′ In Mechanically Ventilated patients 12 < spontaneous breathing patients Diastolic Dysfunction
  17. 17. Diastolic Dysfunction Lung US for B-lines
  18. 18. Cardiogenic Shock Other Causes: Post infarction VSD Acute aortic dissection with AR
  19. 19. Distributive Obstructive Hypovolaemic Cardiogenic Shock
  20. 20. Hypovolemic Shock Assessment of intravascular volume is the beginning in all types of shock Hypovolemia is severe kissing walls Fixed bowing of the atrial septum into the RA throughout the cardiac cycle Elevated Left Atrial Pressure Further Fluids not needed 1 2 Non-specific
  21. 21. Measuring the IVC 0.5– 3 cm from the caval– right atrial junction in the subcostal view
  22. 22. Teboul JL et al. Chest 2001, 119:867–873 Volume Responsiveness Inferior Vena Cava (IVC) Dispensability (TTE subcostal view) >/=18% Superior Vena cava Collapsibility (SVC) (TEE bicaval view) >/= 36% Respiratory variation of LV ejection >/=12.5%
  23. 23. Respiratory Variations
  24. 24. Collapsibility Index CI = (Dmax − Dmin )/Dmax ~ 100 % DI = (Dmax − Dmin )/Dmin In fully supported on Mechanical Ventilation Distensibility Index In the spontaneously breathing patient
  25. 25. SVC Collapsibility Basal After 1500 ml fluids
  26. 26. Pitfalls Not valid patients receiving partial ventilatory support Only valid in the extremes fluid responsiveness is determined if there is, on average, a >15 % increase in SV or CO
  27. 27. IVC Collapsibility Basal After 1500 ml fluids
  28. 28. IVC vs. CVP Guidelines
  29. 29. IVC Pitfalls Volume Overload Obstructive Shock Aortic stenosis RV FailureIntraabdominal Pressure Status Asthmaticus MR
  30. 30. LV end diastolic area (LVEDA) < 5.5 cm/m2 BSA (or < 10 cm2)
  31. 31. Distributive ObstructiveHypovolaemic Cardiogenic Shock
  32. 32. Obstructive Shock Resistance to blood flow through the cardiopulmonary Circulation Causes: acute pulmonary embolus cardiac tamponade type A dissection tension pneumothorax dynamic outflow obstruction
  33. 33. Dilated right chambers decreased cardiac output RV/LV area ratio >0.6; gross dilatation is seen with a ratio >1.0 Acute PE changes in right ventricular contraction elevated pulmonary artery pressures intra‐ cavity emboli Normal Hyperdynamic Hypodynamic
  34. 34. Acute PE PAcT of 70– 90 ms indicates a pulmonary artery systolic pressure of >70 mmHg Mid‐systolic notch also indicates severe pulmonary hypertension D‐ shaped LV
  35. 35. Also in RV infarction The McConnell’s sign Non-specific RV Free wall hypokinesia with preserved apex
  36. 36. When the intra-pericardial pressure exceeds right heart filling pressure (diastole) Cardiac Tamponade Impaired filling of the chambers Cardiac tamponade Physiology
  37. 37. RA systolic collapse for longer than one-third of the cardiac cycle Cardiac Tamponade RV diastolic collapse Echo Findings RA then RVOT then whole RV then LA then LV. Dilated IVC
  38. 38. Cardiac Tamponade Echo Findings
  39. 39. Exaggerated respiratory variations of the mitral and tricuspid inflow (Pulsus Paradoxus) Cardiac Tamponade Echo Findings
  40. 40. Size is not a guide to the presence of tamponade. The opposite of respiratory variations if positive pressure ventilation Cardiac Tamponade Pitfalls Echo is the investigation of choice Guides pericardiocentesis
  41. 41. Typical with basal septal hypertrophy Dynamic LVOT Obstruction close approximation of lateral wall and septum Echo Findings systolic anterior motion of the anterior mitral leaflet. Dagger-shaped Doppler pattern of LVOT flow
  42. 42. Dynamic LVOT Obstruction Causes Acute MI in the apical and mid segments Stress Cardiomyopathy (Takatsubo) Dobutamine in patients with small LV cavity (concentric LVH) Hyperdynamic states (Sepsis, severe anemia) Hypertrophic Cardiomyopathy Sub-aortic membrane: fixed Mitral valve surgery
  43. 43. Pitfalls absence of septal hypertrophy in the elderly Tachycardia, hypovolemia, and inotropes makes critically ill more prone to it Dynamic LVOT Obstruction
  44. 44. Distributive ObstructiveHypovolaemic Cardiogenic Shock
  45. 45. Septic Shock Heart is either the “Source” or the ”Victim” of the septic process Left ventricular dilatation LV, RV Systolic and Diastolic impairment Valvular lesions (Functional, Endocarditis) Ventricular outflow obstruction Echo Findings
  46. 46. Early Septic Shock Small & Collapsing IVC Small LV LV and RV hyperkinesia Small RV A clue to the presence of marked peripheral vasodilatation.
  47. 47. Late Septic Shock Sepsis induced myocardial suppression
  48. 48. April 2015, www.survivingsepsis.org 6-hour Bundle
  49. 49. Pitfalls a normal study is not unusual speckle tracking recently utilized to assess prognosis in such patients Takutsubo Cardiomyopathy is reported Septic Shock Contractile dysfunction is reversible in sepsis over days, unless concomitant CAD or myocarditis.
  50. 50. Chang, WT. et al. Intensive Care Med (2015) 41: 1791 LV GLS provides prognostic information as an outcome predictor for mortality of septic shock patients. 111 ICU pts. with septic shock, over 2 yrs
  51. 51. Echo is the most single useful tool in the diagnosis and Rx of shock Hyperdynamic LV also is highly specific for sepsis (94%). Bedside Echo currently replaces mandatory CVP measurement in Sepsis 1 2 3 take-home messages5 LVOT VTI is a useful surrogate for LV Stroke Volume4 Dynamic serial assessment is the key to proper management.5
  52. 52. Resources EACVI/ACCA recommendation for use of Echo in Acute Cardiac Care Twitter: #POCUS #SMACC #FOAMEd #FOAMus #FOAMcc ACCA Webinar (Critical Care Echo) www.criticalecho.com www.lifeinthefastlane.com www.fate-protocol.com McLean Critical Care (2016) 20:275
  53. 53. EGLS RUSH FATE
  54. 54. Resources
  55. 55. Thank You hatem.soliman@gmail.com @hatemsoliman Any suggestions or input? Contact me at:

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