Presentation on utility of ultrasound in the arena of prehospital and retrieval medicine. I intentionally strayed away from e-FAST & focussed more on the ongoing resuscitation of a medically shocked patient.

1. Ultrasound updates for
prehospital probers...
Chris Partyka
Ultrasound Registrar - Liverpool Hospital

2. Disclaimer
I have not worked in retrieval.
I have not had formal ECHO training.
I have scanned lots of hearts.
I have asked lots of questions & read lots of answers.
I love ultrasound...

5. E-FAST

6. Extending your e-FAST

7. ONSD
normal < 5mm
>5mm ?↑ICP
Sn 84-94%
Sp 76-94%

9. Courtesy of Dr Justin Bowra
Pubic symphysis ultrasound

10. RUSH protocol
Primary US-assessment of undifferentiated shock
leading to a mechanical cause of obstructive shock. Second, the left ventricle can be
analyzed for global contractility. Determination of the size and contractility status of
the left ventricle will allow for those patients with a cardiogenic cause of shock to
be rapidly identified.10,11
The third goal-directed examination of the heart focuses
on determining the relative size of the left ventricle to the right ventricle. A heart that
has an increased size of the right ventricle relative to the left ventricle may be a sign
of acute right ventricular strain from a massive pulmonary embolus in the hypotensive
patient.12,13
The second part of the RUSH shock ultrasound protocol focuses on the determina-
tion of effective intravascular volume status, which will be referred to as ‘‘the tank.’’
Placement of the probe in the subxiphoid position, along both the long and short
axis of the inferior vena cava (IVC), will allow correct determination of the size of the
vessel. Looking at the respiratory dynamics of the IVC will provide an assessment
of the patient’s volume status to answer the clinical question, ‘‘how full is the
Table 1
Rapid Ultrasound in SHock (RUSH) protocol: ultrasonographic findings seen with classic
shock states
RUSH
Evaluation
Hypovolemic
Shock Cardiogenic Shock Obstructive Shock Distributive Shock
Pump Hypercontractile
heart
Small chamber
size
Hypocontractile
heart
Dilated heart
Hypercontractile
heart
Pericardial effusion
Cardiac
tamponade
RV strain
Cardiac thrombus
Hypercontractile
heart (early sepsis)
Hypocontractile
heart (late sepsis)
Tank Flat IVC
Flat jugular
veins
Peritoneal fluid
(fluid loss)
Pleural fluid
(fluid loss)
Distended IVC
Distended jugular
veins
Lung rockets
(pulmonary
edema)
Pleural fluid
Peritoneal fluid
(ascites)
Distended IVC
Distended jugular
veins
Absent lung sliding
(pneumothorax)
Normal or small IVC
(early sepsis)
Peritoneal fluid
(sepsis source)
Pleural fluid (sepsis
source)
Pipes Abdominal
aneurysm
Aortic
dissection
Normal DVT Normal
Abbreviations: DVT, deep venous thrombosis; IVC, inferior vena cava; RV, right ventricle.

11. FALLS protocol
Fluid Administration Limited by
Lung Sonography

12. BRIEF REPORT
Use of point-of-care ultrasound by a critical
care retrieval team
Stefan M Mazur,1,3
Andrew Pearce,1,2
Sam Alfred1,2
and Peter Sharley1,4
1
Royal Adelaide Hospital Mediflight, Critical Care Retrieval Service, 2
Royal Adelaide Hospital Emergency
Department, 4
Royal Adelaide Hospital Intensive Care Unit, Adelaide, SA and 3
Royal Perth Hospital
Emergency Department Perth, WA, Australia
Abstract
Point-of-care ultrasound in the prehospital and retrieval environments has now become
possible owing to decreased size and weight, and increasing robustness of some ultrasound
machines. This report describes the initial experience of point-of-care ultrasound by an
Australian critical care retrieval service using a portable ultrasound machine.
Key words: critical care, patient transport, point-of-care, prehospital, retrieval, ultrasound.
Introduction
Retrieval medicine is a continuously evolving medical
subspecialty in Australia. Having a critical care special-
ist retrieve and transport patients with significant
potential morbidity and mortality has been shown to
improve patient outcome.1,2
Point-of-care ultrasound is a limited, goal-directed
examination performed to answer specific clinical ques-
tions. Critical care specialists use ultrasound for focused
assessment by sonography in trauma (FAST) and
abdominal aortic aneurysm (AAA) diagnosis, as well as
to answer specific clinical questions, such as, presence
of ectopic pregnancy,3
presence of gallstones.4
Ultra-
sound is also used to aid in invasive procedures, such
as, central line placement,5
pericardial aspiration,4
to
minimize iatrogenic complications and improve proce-
dure success rates.
With increasing ultrasound use in emergency medi-
cine, intensive care and anaesthesia, it is logical that
those specialists who use ultrasound in these environ-
ments should consider the applicability of this technol-
ogy in the other areas that they work in, notably the
prehospital and retrieval environment.6,7
Retrieval physicians could potentially improve criti-
cal patient care with access to point-of-care ultrasound
in a number of ways:
• Early diagnosis7,8
and commencement of appropriate
treatment
• Decreased risk of iatrogenic injury in patients requir-
ing invasive procedures
• Enhanced accuracy of communication with receiving
hospitals on likely management and personnel
requirements
• Decreased time to definitive care
Royal Adelaide Hospital (RAH) Mediflight (Adelaide,
Australia) is a hospital-based critical care retrieval
service that performs prehospital and interhospital
medical retrievals for critically ill patients. Retrieval
teams consist of a doctor and nurse from one of the
Correspondence: Dr Stefan M Mazur, CareFlight Medical Services, PO Box 829, Aitkenvale, Qld 4814, Australia. Email: stefanm@
careflightmedical.org.au
Stefan M. Mazur BPhEd, MBChB, PGCertAME, FACEM; Andrew Pearce, BSc (Hons), BMBS, FACEM; Sam Alfred, MB BS, FACEM;
Peter Sharley, MB BS, DipObsRACOG, PGDipAvMed, FANZCA, FJFICM.
doi: 10.1111/j.1742-6723.2007.01029.x Emergency Medicine Australasia (2007) 19, 547–552
© 2007 The Authors
Journal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
BioMed CentralBMC Medical Education
Open AccessResearch article
Evaluation of a thoracic ultrasound training module for the
detection of pneumothorax and pulmonary edema by prehospital
physician care providers
Vicki E Noble*†1, Lionel Lamhaut†2, Roberta Capp†1, Nichole Bosson†1,
Andrew Liteplo†1, Jean-Sebastian Marx†2 and Pierre Carli†2
Address: 1Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, Massachusetts, USA and 2SAMU de Paris,
Hôpital Necker – Enfants Malades, 149 Rue de Sèvres, 75743 Paris Cedex 15, France
Email: Vicki E Noble* - vnoble@partners.org; Lionel Lamhaut - lamhautl@gmail.com; Roberta Capp - rcapp@partners.org;
Nichole Bosson - nichole.bosson@gmail.com; Andrew Liteplo - aliteplo@partners.org; Jean-Sebastian Marx - jean-sebastien.marx@nck.aphp.fr;
Pierre Carli - pcarli.secretariat@nck.aphp.fr
* Corresponding author †Equal contributors
Published: 12 January 2009
BMC Medical Education 2009, 9:3 doi:10.1186/1472-6920-9-3
Received: 21 July 2008
Accepted: 12 January 2009
This article is available from: http://www.biomedcentral.com/1472-6920/9/3
BMC Medical Educa
Research article
Evaluation of a thoracic ultrasoun
detection of pneumothorax and p
physician care providers
Vicki E Noble*†1, Lionel Lamhaut†2, R
Andrew Liteplo†1, Jean-Sebastian Marx
Address: 1Department of Emergency Medicine, Massachusetts General H
Hôpital Necker – Enfants Malades, 149 Rue de Sèvres, 75743 Paris Cede
Email: Vicki E Noble* - vnoble@partners.org; Lionel Lamhaut - lamhau
Nichole Bosson - nichole.bosson@gmail.com; Andrew Liteplo - aliteplo
Pierre Carli - pcarli.secretariat@nck.aphp.fr
* Corresponding author †Equal contributors
Abstract
Background: While ultrasound (US) has continue
physicians inside the hospital system, the technology
Given the diagnostic benefits of thoracic ultrasound
Published: 12 January 2009
BMC Medical Education 2009, 9:3 doi:10.1186/1472-6920-9-3
This article is available from: http://www.biomedcentral.com/1472-6920/9/3
© 2009 Noble et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative C
which permits unrestricted use, distribution, and reproduction in any medium
RESEARCH Open Access
Combination of lung ultrasound (a comet-tail
sign) and N-terminal pro-brain natriuretic peptide
in differentiating acute heart failure from chronic
obstructive pulmonary disease and asthma as
cause of acute dyspnea in prehospital
emergency setting
Gregor Prosen1,2
, Petra Klemen1,2,3
, Matej Strnad1,2
and Štefek Grmec1,2,3,4*
Abstract
Introduction: We studied the diagnostic accuracy of bedside lung ultrasound (the presence of a comet-tail sign),
N-terminal pro-brain natriuretic peptide (NT-proBNP) and clinical assessment (according to the modified Boston
criteria) in differentiating heart failure (HF)-related acute dyspnea from pulmonary (chronic obstructive pulmonary
disease (COPD)/asthma)-related acute dyspnea in the prehospital setting.
Methods: Our prospective study was performed at the Center for Emergency Medicine, Maribor, Slovenia, between
July 2007 and April 2010. Two groups of patients were compared: a HF-related acute dyspnea group (n = 129) and
a pulmonary (asthma/COPD)-related acute dyspnea group (n = 89). All patients underwent lung ultrasound
examinations, along with basic laboratory testing, rapid NT-proBNP testing and chest X-rays.
Results: The ultrasound comet-tail sign has 100% sensitivity, 95% specificity, 100% negative predictive value (NPV)
and 96% positive predictive value (PPV) for the diagnosis of HF. NT-proBNP (cutoff point 1,000 pg/mL) has 92%
sensitivity, 89% specificity, 86% NPV and 90% PPV. The Boston modified criteria have 85% sensitivity, 86% specificity,
80% NPV and 90% PPV. In comparing the three methods, we found significant differences between ultrasound sign
and (1) NT-proBNP (P < 0.05) and (2) Boston modified criteria (P < 0.05). The combination of ultrasound sign and
NT-proBNP has 100% sensitivity, 100% specificity, 100% NPV and 100% PPV. With the use of ultrasound, we can
exclude HF in patients with pulmonary-related dyspnea who have positive NT-proBNP (> 1,000 pg/mL) and a
history of HF.
Conclusions: An ultrasound comet-tail sign alone or in combination with NT-proBNP has high diagnostic accuracy
in differentiating acute HF-related from COPD/asthma-related causes of acute dyspnea in the prehospital
emergency setting.
Trial registration: ClinicalTrials.gov NCT01235182.
* Correspondence: grmec-mis@siol.net
1
Center for Emergency Medicine, Ulica talcev 9, 2000 Maribor, Slovenia
Full list of author information is available at the end of the article
http://ccforum.com/content/15/2/R114
© 2011 Prosen et al.; licensee BioMed Central Ltd This is an open access article distributed under the terms of the Creative Commons
Attribution License http://creativecommons.org/licenses/by/2.0, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited
RESEARCH
Combination of lun
sign) and N-termin
in differentiating a
obstructive pulmon
cause of acute dys
emergency setting
Gregor Prosen1,2
, Petra Klemen1,2,3
, Matej
Abstract
Introduction: We studied the diagnostic
N-terminal pro-brain natriuretic peptide (N
criteria) in differentiating heart failure (HF)
disease (COPD)/asthma)-related acute dysp
Methods: Our prospective study was perf
July 2007 and April 2010. Two groups of p
a pulmonary (asthma/COPD)-related acute
examinations, along with basic laboratory
Results: The ultrasound comet-tail sign ha
and 96% positive predictive value (PPV) fo
sensitivity, 89% specificity, 86% NPV and 9
80% NPV and 90% PPV. In comparing the
and (1) NT-proBNP (P < 0.05) and (2) Bost
NT-proBNP has 100% sensitivity, 100% spe
Prosen et al. Critical Care 2011, 15:R114
http://ccforum.com/content/15/2/R114
Resuscitation 81 (2010) 1527–1533
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
Focused echocardiographic evaluation in life support and peri-resuscitation of
emergency patients: A prospective trialଝ,ଝଝ
Raoul Breitkreutza,e,∗
, Susanna Priceb
, Holger V. Steigerc
, Florian H. Seegerd
, Hendrik Ilpere
,
Hanns Ackermannf
, Marcus Rudolphg
, Shahana Uddinh
, Markus A. Weigandi
, Edgar Müllerj
,
Felix Walcherk
, from the Emergency Ultrasound Working Group of the Johann Wolfgang
Goethe-University Hospital, Frankfurt am Main1
a
Department of Anaesthesiology, Intensive Care and Pain Therapy University of the Saarland, Medical Faculty, D-66421 Homburg (Saar), Germany
b
Adult Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
c
Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
d
Department of Cardiology, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
e
Clinics of Anaesthesiology, Intensive Care and Pain Therapy, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
f
Institute for Bioinformatics and Statistical Analysis, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
g
Department of Anaesthesiology and Intensive Care Medicine, Klinikum Ludwigshafen/Rhein, Germany
h
Department of Anaesthesia, Barts & the London NHS Trust, London, United Kingdom
i
Department of Anaesthesiology, Intensive Care and Pain therapy, Justus-Liebig-University, Giessen, Germany
j
Emergency Medical Service of the Darmstadt Hospital, Germany
k
Trauma Surgery, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
a r t i c l e i n f o
Article history:
Received 11 April 2010
Received in revised form 29 June 2010
Accepted 23 July 2010
Keywords:
Peri-resuscitation
FEEL
Cardio-pulmonary resuscitation
CPR
Ultrasound
Echocardiography
a b s t r a c t
Purpose of the study: Focused ultrasound is increasingly used in the emergency setting, with an ALS-
compliant focused echocardiography algorithm proposed as an adjunct in peri-resuscitation care (FEEL).
The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence
of potentially treatable conditions detected, and the influence on patient management.
Patients, materials and methods: A prospective observational study in a pre-hospital emergency setting
in patients actively undergoing cardio-pulmonary resuscitation or in a shock state. The FEEL protocol
was applied by trained emergency doctors, following which a standardised report sheet was completed,
including echo findings and any echo-directed change in management. These reports were then analysed
independently.
Results: A total of 230 patients were included, with 204 undergoing a FEEL examination during ongoing
cardiac arrest (100) and in a shock state (104). Images of diagnostic quality were obtained in 96%. In 35%
of those with an ECG diagnosis of asystole, and 58% of those with PEA, coordinated cardiac motion was
Resuscitation 81 (2010) 1527–1533
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
inical paper
Review 249
Does prehospital ultrasound improve treatment of the trauma
patient? A systematic review
Henrik Jørgensena
, Carsten H. Jensenb
and Jesper Dirksa
Ultrasound (US) has been used for in-hospital evaluation haemoperitoneum or haemopericardium compared
Review 249
al ultrasound improve treatment of the trauma
ematic review
Carsten H. Jensenb
and Jesper Dirksa
ed for in-hospital evaluation
years. The outcome
mains heavily influenced by
e, as time plays a major role.
tery-powered, low-weight
possibility of bringing US
s gaining a potential for early
objective of this study was
terature for evidence that
n or thorax increases survival
egarding the use of US in
se, often of low quality
y of patients and clinical
haemoperitoneum or haemopericardium compared
with the low accuracy of physical examination and
haemodynamic measurements. An early diagnosis will
provide the prehospital physician with the knowledge to
prioritize the relevant initial treatment and to choose the
closest appropriate hospital and transportation form. There
is currently no evidence in the literature that prehospital US
of the abdomen or thorax improves treatment of trauma
patients. European Journal of Emergency Medicine
17:249–253
c 2010 Wolters Kluwer Health | Lippincott
Williams & Wilkins.
European Journal of Emergency Medicine 2010, 17:249–253
Resuscitation 85 (2014) 21–30
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Review article
Effect of prehospital ultrasound on clinical outcomes of non-trauma
patients—A systematic reviewଝ
Søren Steemann Rudolpha,b,∗
, Martin Kryspin Sørensenb
, Christian Svanea,b
,
Rasmus Hesselfeldtb
, Jacob Steinmetza,b
a
The Emergency Medical Services in Copenhagen, Denmark
b
Centre of Head and Orthopaedics, Department of Anaesthesia, Rigshospitalet, Denmark
a r t i c l e i n f o
Article history:
Received 4 June 2013
Received in revised form 18 August 2013
Accepted 15 September 2013
Keywords:
Prehospital care
Ultrasound
Systematic review
Out of hospital cardiac arrest
Echocardiography
Lung ultrasound
a b s t r a c t
Background: Advances in technology have made prehospital ultrasound (US) examination available.
Whether US in the prehospital setting can lead to improvement in clinical outcomes is yet unclear.
Objective: The aim of this systematic review was to assess whether prehospital US improves clinical
outcomes for non-trauma patients.
Method: We conducted a systematic review on non-trauma patients who had an US examination per-
formed in the prehospital setting. We searched MEDLINE, EMBASE, the Cochrane Central Register of
Controlled Trials and the ISI Web of Science and the references of the included studies for additional
relevant studies. We then performed a risk of bias analysis and descriptive data analysis.
Results: We identified 1707 unique citations and included ten studies with a total of 1068 patients under-
going prehospital US examination. Included publications ranged from case series to non-randomized,
descriptive studies, and all showed a high risk of bias. The large heterogeneity between the different
studies made further statistical analysis impossible.
Conclusion: There are currently no randomized, controlled studies on the use of US for non-trauma
patients in the prehospital setting. The included studies were of large heterogeneity and all showed
a high risk of bias. We were thus unable to assess the effect of prehospital US on clinical outcomes. How-
ever, consistent reports suggested that US may improve patient management with respect to diagnosis,
treatment, and hospital referral.
© 2013 Elsevier Ireland Ltd. All rights reserved.
Resuscitation 85 (2014) 21–30
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscita
Review article
Effect of prehospital ultrasound on clinical outcomes of non
n Rudolpha,b,∗
, Martin Kryspin Sørensenb
, Christian Svanea,b
,
eldtb
, Jacob Steinmetza,b
ervices in Copenhagen, Denmark
paedics, Department of Anaesthesia, Rigshospitalet, Denmark
f o
18 August 2013
013
est
a b s t r a c t
Background: Advances in technology have made prehospital ultrasound (US) examination available.
Whether US in the prehospital setting can lead to improvement in clinical outcomes is yet unclear.
Objective: The aim of this systematic review was to assess whether prehospital US improves clinical
outcomes for non-trauma patients.
Method: We conducted a systematic review on non-trauma patients who had an US examination per-
formed in the prehospital setting. We searched MEDLINE, EMBASE, the Cochrane Central Register of
Controlled Trials and the ISI Web of Science and the references of the included studies for additional
relevant studies. We then performed a risk of bias analysis and descriptive data analysis.
Results: We identified 1707 unique citations and included ten studies with a total of 1068 patients under-
going prehospital US examination. Included publications ranged from case series to non-randomized,
descriptive studies, and all showed a high risk of bias. The large heterogeneity between the different
studies made further statistical analysis impossible.
Conclusion: There are currently no randomized, controlled studies on the use of US for non-trauma
patients in the prehospital setting. The included studies were of large heterogeneity and all showed
a high risk of bias. We were thus unable to assess the effect of prehospital US on clinical outcomes. How-
ever, consistent reports suggested that US may improve patient management with respect to diagnosis,
treatment, and hospital referral.
© 2013 Elsevier Ireland Ltd. All rights reserved.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
and registration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

14. + LV function

15. Reasonable LV function

16. Clearly terrible...

17. TAMPONADE !
Now get me a needle...

24. Tamponade on ECHO
RA diastolic collapse
RV diastolic collapse
MV inflow pulsus paradoxus
Dilated, non-collapsing IVC

25. MASSIVE PE !
Draw up the ‘lytics...

27. septal
bowing
RV
LV
RV >> LV

30. RV
LV

31. Clot in transit

32. RV strain on ECHO
RV:LV > 0.9
RV >30 mm
RV (free-wall) hypokinesis
McConnell’s sign
Paradoxical septal motion
Editor’s Capsule Summary
What is already known on this topic
Right ventricular dysfunction on echocardiography is
associated with a worse prognosis in pulmonary
embolism. Prompt treatment of pulmonary
embolism appears to be associated with better
outcomes.
What question this study addressed
Can emergency department bedside
echocardiography in patients with suspected
pulmonary embolism reliably identify those who have
right ventricular dysfunction, potentially leading to
earlier diagnosis and treatment?
What this study adds to our knowledge
This observational study of a convenience sample of
146 patients with moderate to high risk or confirmed
pulmonary embolism found that right ventricular
dysfunction was highly specific for pulmonary
embolism.
How this is relevant to clinical practice
Bedside echocardiography may be a useful addition
disposition could be expedited, resulting in a possible reduction
in morbidity and mortality.
Figure 1. Right ventricular dilatation (right ventricle:left
ventricle ratio >1:1) in this apical 4-chamber image of a
patient with an acute pulmonary embolism. RV, right ventricle;
LV, left ventricle; RA, right atrium; LA, left atrium.
Dresden et al Bedside Echocardiography for Diagnosis of Pulmonary Embolism

33. McConnell sign

34. PNEUMOTHORAX !
Now get me a scalpel...

36. Normal lung...
Comet
tails
A-lines

41. For GODs SAKE!!
Stop the fluids & start some
inotropes...
B - PROFILE

44. Lung rockets [aka. B-lines]
1. A comet tail
2. Arises from pleural line
3. Moves in concert with lung sliding
4. Does NOT fade
5. Laser-like, ie. well defined
6. Hyperechoic
7. Obliterates the A-lines
144 of acute circulatory failure are competing:
hypovolemic shock and distributive shock.
In this context distributive shock is assim-
ilated to septic shock not simply for sake
of simplicity, but also because the other
causes (anaphyllactic, spinal shock) are
infrequent and easy to be diagnosed. The
A-profile is correlated with a pulmonary ar-
tery occlusion pressure (PAOP) equal to or
lower than 18 mmHg with a 93% specific-
ity and 97% positive predictive value (2). A
shocked patient who displays the A-profile,
at this step, is called a FALLS-responder.
This patient can, and needs to receive fluid.
The FALLS-protocol is a therapeutic test.
It administers fluid with strict monitoring
of the clinical parameters of circulation
an
plo
of
pro
eve
cir
(w
sho
cas
wo
he
peu
Di
If
id
ove
lun
ter
cha
the
mm
an
Th
det
an
ste
is d
nis
cau
the
ram
“false-positives” makes little sense when another sign
is added: the A-line sign (i.e., no B-line seen), with
60% sensitivity but 100% specificity, a logical finding
interlobular septa come only from visceral pleura [23]
One motionless B-line discounts pneumothorax. Too
superficial linear probes make it difficult to distinguish
B-lines from other comet-tail artifacts (Figure 5)
Abolished lung-sliding plus absence of B-lines, at the
anterior area, in supine patients, is called A’-profile in
the BLUE-protocol (Figure 6). The third step—the
Figure 5 Interstitial syndrome and the lung rockets. Two examples
the text) are visible, called lung rockets (here septal rockets correlating w
called ground-glass rockets. Two examples of pulmonary edema (with gr
These parasites are ill-defined, short, and do not erase A-lines (arrows), am
ill” (2010 Ed, Chapter 17), with kind permission of Springer Science.
Lichtenstein Annals of Intensive Care 2014, 4:1
http://www.annalsofintensivecare.com/content/4/1/1

45. Lung rockets [aka. B-lines]
1. A comet tail
2. Arises from pleural line
3. Moves in concert with lung sliding
4. Does NOT fade
5. Laser-like, ie. well defined
6. Hyperechoic
7. Obliterates the A-lines
144 of acute circulatory failure are competing:
hypovolemic shock and distributive shock.
In this context distributive shock is assim-
ilated to septic shock not simply for sake
of simplicity, but also because the other
causes (anaphyllactic, spinal shock) are
infrequent and easy to be diagnosed. The
A-profile is correlated with a pulmonary ar-
tery occlusion pressure (PAOP) equal to or
lower than 18 mmHg with a 93% specific-
ity and 97% positive predictive value (2). A
shocked patient who displays the A-profile,
at this step, is called a FALLS-responder.
This patient can, and needs to receive fluid.
The FALLS-protocol is a therapeutic test.
It administers fluid with strict monitoring
of the clinical parameters of circulation
an
plo
of
pro
eve
cir
(w
sho
cas
wo
he
peu
Di
If
id
ove
lun
ter
cha
the
mm
an
Th
det
an
ste
is d
nis
cau
the
ram
“false-positives” makes little sense when another sign
is added: the A-line sign (i.e., no B-line seen), with
60% sensitivity but 100% specificity, a logical finding
interlobular septa come only from visceral pleura [23]
One motionless B-line discounts pneumothorax. Too
superficial linear probes make it difficult to distinguish
B-lines from other comet-tail artifacts (Figure 5)
Abolished lung-sliding plus absence of B-lines, at the
anterior area, in supine patients, is called A’-profile in
the BLUE-protocol (Figure 6). The third step—the
Figure 5 Interstitial syndrome and the lung rockets. Two examples
the text) are visible, called lung rockets (here septal rockets correlating w
called ground-glass rockets. Two examples of pulmonary edema (with gr
These parasites are ill-defined, short, and do not erase A-lines (arrows), am
ill” (2010 Ed, Chapter 17), with kind permission of Springer Science.
Lichtenstein Annals of Intensive Care 2014, 4:1
http://www.annalsofintensivecare.com/content/4/1/1
Dx = acute cardiogenic pulmonary oedema
Sn 97%, Sp 95%

47. The lungs are DRY
Give more fluids...
A - PROFILE

49. Trauma applicability ?
20-something male, 4 metre fall.
Severe respiratory distress + hypoxia
Agitated + combative → ketamine
L. subcut emphysema

50. Trauma applicability ?
Courtesy of Dr Justin Bowra
Left anterior chest

51. Trauma applicability ?
Courtesy of Dr Justin Bowra
Left lateral chest

52. Trauma applicability ?
Courtesy of Dr Justin Bowra
Left lateral chest
Lung
sliding
B-lines
PULMONARY
CONTUSION !!

53. References
Perera, P., Mailhot, T., Riley, D., & Mandavia, D. (2010). The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emergency
medicine clinics of North America, 28(1), 29–56– vii. doi:10.1016/j.emc.2009.09.010
Seif, D., Perera, P., Mailhot, T., Riley, D., & Mandavia, D. (2012). Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock Protocol.
Critical Care Research and Practice, 2012(3), 1–14. doi:10.1097/01.CCM.0000260680.16213.26
Lichtenstein, D. (2013). FALLS-protocol: lung ultrasound in hemodynamic assessment of shock. Heart, lung and vessels, 5(3), 142–147.
Lichtenstein, D. A. (2014). Lung ultrasound in the critically ill. Annals of intensive care, 4(1), 1. doi:10.1186/2110-5820-4-1
Lichtenstein, D. A., & Mezière, G. A. (2008). Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest, 134
(1), 117–125. doi:10.1378/chest.07-2800
MD, S. D., et al. (2014). Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of
Pulmonary Embolism. Annals of Emergency Medicine, 63(1), 16–24. doi:10.1016/j.annemergmed.2013.08.016
Nagdev, A. D., Merchant, R. C., Tirado-Gonzalez, A., Sisson, C. A., & Murphy, M. C. (2010). Emergency department bedside ultrasonographic
measurement of the caval index for noninvasive determination of low central venous pressure. Annals of Emergency Medicine, 55(3), 290–295. doi:
10.1016/j.annemergmed.2009.04.021
Meyer, G., Vicaut, E., Danays, T., Agnelli, G., Becattini, C., Beyer-Westendorf, J., et al. (2014). Fibrinolysis for Patients with Intermediate-Risk
Pulmonary Embolism. The New England journal of medicine, 370(15), 1402–1411. doi:10.1056/NEJMoa1302097
Sosland, R. P., & Gupta, K. (2008). Images in cardiovascular medicine: McConnell's Sign. Circulation, 118(15), e517–8. doi:10.1161/
CIRCULATIONAHA.107.746602
Rudski, L. G.., et al. (2010). Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of
Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the
Canadian Society of Echocardiography. Journal of the American Society of Echocardiography : official publication of the American Society of
Echocardiography, 23(7), 685–713– quiz 786–8. doi:10.1016/j.echo.2010.05.010
http://resus.me/prehospital-ultrasound/

55. any questions ??