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Introduction to critical care US SAH & RNSH 2011 Critical Care Ultrasound Course
Goals of today's course ,[object Object],[object Object],[object Object],[object Object],[object Object]
A real case (My road to Damascus) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Initial investigations ,[object Object],[object Object],[object Object]
Atypical pneumonia? Or a PE?
OK, let ’ s get a scan. ,[object Object],[object Object],[object Object]
#*%* !!!
Get out the ED US machine! ,[object Object],[object Object],[object Object],[object Object]
Lungs clear
Non-collapsing IVC
RV > LV
DVT
Results ,[object Object],[object Object],[object Object],[object Object],[object Object]
Massive PE ,[object Object],[object Object],[object Object]
Essential features of any bedside test in critical care ,[object Object],[object Object],[object Object],[object Object],[object Object]
BSL ECG O2 Sats
Bedside Critical Care US (CCUS)
Why? ,[object Object],[object Object],[object Object],[object Object],[object Object]
What is critical care US? ,[object Object],[object Object],[object Object],[object Object]
Why isn't focused TTE enough? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Does the screen really take 3 minutes?
Why isn't focused TTE enough? ,[object Object]
Duh! Just look at the left thorax
This is why focused TTE isn ’ t enough ,[object Object],[object Object]
Whole-body  ultrasound
Current standard of critical care ultrasound ,[object Object],[object Object],[object Object],[object Object]
An important note ,[object Object],[object Object],[object Object]
Top tip: bloody sick = bloody obvious We're not looking for small pneumothorax or mild CCF ('rule-in', not 'rule-out') If the patient is unstable, the US signs should be obvious
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],What this isn't
Limitations of critical care US ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
So: the golden rules 1.  'Resus-only':  Patient must be critically unwell: shocked / breathless / peri-arrest.  That's because the US signs of some of these diseases are only reliably present if  severe  eg  massive  PE,  severe  pneumonia. If formal studies are needed after resus, get them. 2. Clinical context is paramount.  Make a differential diagnosis list before you switch on the machine. All data must be considered (eg FBC with Hb = 4). 3. Only ask questions that you can answer.  Leave the fancy stuff (eg valve disease) to others. 4. Repeat scans are crucial  during resuscitation & each time clinical picture changes.
Golden rules 5. 90% = 100%:  Every test has its limitations. In a periarrest patient, no study will be 100% accurate. If this bothers you, don't practise critical care. RNSH respiratory physician: 'Would you really thrombolyse a critically ill patient with suspected PE on the basis of bedside US?' ED physician answer: 'I spent years doing just that without the benefit of US. Anything that improves my accuracy suits me fine.'
Golden rules 6. When in doubt, be a doctor.  You were a clinician before you were a sonographer. If the clinical picture & scan findings don’t agree,  believe the clinical picture. ‘ What would I diagnose if I didn’t have an US machine?’
The golden rules 1. 'Resus-only' 2. Clinical context is paramount. 3. Only ask questions that you can answer. 4. Repeat scans are crucial. 5. 90% = 100% 6. When in doubt, be a doctor.
7. A fool with a stethoscope will be a fool with an ultrasound
Critical care US ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Thanks to Daniel Lichtenstein Paul Atkinson Conn Russell Rob Reardon Vicki Noble Russell McLaughlin (for rule #7)
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PS Even if I hand't performed an US, I probably still would ’ ve thrombolysed him.

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Introduction to Critical Care Ultrasound

  • 1. Introduction to critical care US SAH & RNSH 2011 Critical Care Ultrasound Course
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  • 12. DVT
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  • 16. BSL ECG O2 Sats
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  • 21. Does the screen really take 3 minutes?
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  • 23. Duh! Just look at the left thorax
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  • 28. Top tip: bloody sick = bloody obvious We're not looking for small pneumothorax or mild CCF ('rule-in', not 'rule-out') If the patient is unstable, the US signs should be obvious
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  • 31. So: the golden rules 1. 'Resus-only': Patient must be critically unwell: shocked / breathless / peri-arrest. That's because the US signs of some of these diseases are only reliably present if severe eg massive PE, severe pneumonia. If formal studies are needed after resus, get them. 2. Clinical context is paramount. Make a differential diagnosis list before you switch on the machine. All data must be considered (eg FBC with Hb = 4). 3. Only ask questions that you can answer. Leave the fancy stuff (eg valve disease) to others. 4. Repeat scans are crucial during resuscitation & each time clinical picture changes.
  • 32. Golden rules 5. 90% = 100%: Every test has its limitations. In a periarrest patient, no study will be 100% accurate. If this bothers you, don't practise critical care. RNSH respiratory physician: 'Would you really thrombolyse a critically ill patient with suspected PE on the basis of bedside US?' ED physician answer: 'I spent years doing just that without the benefit of US. Anything that improves my accuracy suits me fine.'
  • 33. Golden rules 6. When in doubt, be a doctor. You were a clinician before you were a sonographer. If the clinical picture & scan findings don’t agree, believe the clinical picture. ‘ What would I diagnose if I didn’t have an US machine?’
  • 34. The golden rules 1. 'Resus-only' 2. Clinical context is paramount. 3. Only ask questions that you can answer. 4. Repeat scans are crucial. 5. 90% = 100% 6. When in doubt, be a doctor.
  • 35. 7. A fool with a stethoscope will be a fool with an ultrasound
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  • 37. Thanks to Daniel Lichtenstein Paul Atkinson Conn Russell Rob Reardon Vicki Noble Russell McLaughlin (for rule #7)
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  • 39. PS Even if I hand't performed an US, I probably still would ’ ve thrombolysed him.