急诊超声对于休克患者的鉴别诊断.ppt

急诊科医生主导的床旁超声技术在急诊临床中的应用 北京协和医院急诊科刘继海2015 4 主要内容 急诊超声和普通超声的区别 以不明原因休克患者RUSH检查为例进一步阐释急诊超声的重要性急诊超声的未来发展方向 急诊超声技术的开展带来的冲击 争地盘 或 抢饭碗 该不该做 资质问题 与 收费问题 如何做 难做吗 与 做得准吗 培训与质量控制如何解决 急诊超声vs 普通超声 急诊医生床旁超声检查旨在最短的时间内得到明确的诊断线索 带着问题进行超声检查 患者各浆膜腔有液体吗 患者有腹主动脉瘤吗 患者有宫内妊娠吗 患者有深静脉血栓吗 患者的心脏在收缩吗 正常还是异常 急诊超声应用范畴 与医疗质量息息相关 危重患者的快速有针对性的超声检查 提高诊断效率 FAST AAA CardiacinPEAorhypotension改进患者的流程 减少急诊滞留时间 DVT Pelvicsonoinearlypregnancy帮助我们完成一些操作 降低风险 Centrallines abscesses LPs 急诊超声有别于传统的超声检查 传统的超声检查更加注重某个脏器病变的检查和描述 急诊超声则从临床出发 有目的的对急诊患者进行超声的重点扫查 对于患者的疾病状态和脏器功能状况做出更为直观的评价 并根据检查的结果对患者进一步治疗和处置提出指导意见 由急诊医师主导的超声检查技术 被誉为 急诊医师的可视听诊器 评估危重症患者病情 对于危及生命的急诊疾病做出快速的诊断提高了急诊患者的诊治效率 引导临床侵入性操作及指导相关急诊状况的处置等 有效降低了侵入性操作并发症的发生率 病例 24岁女性 58公斤 既往健康 仅口服避孕药 因 晕倒 被急救车送入院 病人意识模糊 病史有限 GCS 格拉斯哥昏迷评分 5 6 BP73 42 脉搏80次 分 体温38 3 SpO292 在吸氧4升 分钟的情况下 呼吸26次 分 大汗 右小腿及脚部明显肿胀 胸片无明显异常 心电图 窦性心律 血糖4 3mM L 可能的诊断 RUSHExam Thistechnologyisidealinthecareofthecriticalpatientinshock andthemostrecentACEPguidelinesfurtherdelineateanewcategoryof resuscitative ultrasound Step1 Thepump 泵 Step2 Thetank 血容量 Step3 Thepipes 血管 Step1 EvaluationofthePump Effusionaroundthepump evaluationofthepericardium Squeezeofthepump determinationofgloballeftventricularfunction Strainofthepump assessmentofrightventricularstrain EvaluationofthePump Normalsubxiphoid Normalparasternallong Normalparasternalshort Lateralwall Normalparasternalshortatlevelofaorticvalve Normalapical4 Lateralwall Normalapical2 Anteriorwall Pericardialeffusion Cardiactamponade Squeezeofthepump determinationof howstrongthepumpis avisualcalculationofthepercentagechangefromdiastoletosystoleMotionofanteriorleafletofthemitralvalvecanalsobeusedtoassesscontractility Normalparasternallong Normalparasternalshort Lateralwall Aneasysystemofgrading Tojudgethestrengthofcontractionsasgood withthewallsoftheventriclecontractingwellduringsystole Poor withtheendocardialwallschanginglittleinpositionfromdiastoletosystole Intermediate withthewallsmovingwithapercentagechangeinbetweentheprevious2categories Benefits KnowingthestrengthofleftventricularcontractilitywillgivetheEPabetterideaofhowmuchfluid thepump orheartofthepatientcanhandle beforemanifestingsignsandsymptomsoffluidoverload Incardiacarrest theclinicianshouldspecificallyexamineforthepresenceorabsenceofcardiaccontractions Strainofthepump Onbedsideechocardiography thenormalratioofthelefttorightventricleis1 0 6 Theoptimalcardiacviewsfordeterminingthisratioofsizebetweenthe2ventriclesaretheparasternallongandshort axisviewsandtheapical4 chamberview RightVentricleStrain ThrombusinRA DifferentialDiagnosis MassivePESmallerandrecurrentpulmonaryemboliCorpulmonalePrimarypulmonaryarteryhypertensionAcuterightheartstrainthusdiffersfromchronicrightheartstraininthatalthoughbothconditionscausedilationofthechamber theventriclewillnothavethetimetohypertrophyifthetimecourseissudden Evaluationofthepipes Step2 EvaluationoftheTank Fullnessofthetank evaluationoftheinferiorcavaandjugularveinsforsizeandcollapsewithinspiration Leakinessofthetank FASTexamandpleuralfluidassessment Tankcompromise pneumothorax Tankoverload pulmonaryedema EvaluationoftheTank Fullnessofthetank M modeDoppler Howtodetermine AsmallercaliberIVC 2cmdiameter thatcollapseslessthan50 withinspirationcorrelatestoaCVPofmorethan10cmofwater Thisphenomenonmaybeseenincardiogenicandobstructiveshockstates Highcardiacfillingpressure Twocaveatstothisruleexist Thefirstisinpatientswhohavereceivedtreatmentwithvasodilatorsand ordiureticspriortoultrasoundevaluationinwhomtheIVCmaybesmallerthanpriortotreatment alteringtheinitialphysiologicalstate Thesecondcaveatexistsinintubatedpatientsreceivingpositivepressureventilation inwhichtherespiratorydynamicsoftheIVCarereversed Leakinessofthetank FASTexamandpleuralfluidassessmentIntraumaticconditions asaresultofa holeinthetank leadingtohypovolemicshock Innontraumaticconditions accumulationofexcessfluidintotheabdominalandchestcavitiesoftensignifies tankoverload Ininfectiousstates pneumoniamaybeaccompaniedbyacomplicatingparapneumonicpleuraleffusion andascitesmayleadtospontaneousbacterialperitonitis Rightupperquatrant Leftupperquadrant Pelvicfreefluid Tankcompromise pneumothorax pneumothorax Tankoverload pulmonaryedema Toassessforpulmonaryedemawithultrasound thelungsarescannedwiththephased arraytransducerintheanterolateralchestbetweenthesecondandfifthribinterspaces ThepresenceofBlinescoupledwithdecreasedcardiaccontractilityandaplethoricIVConfocusedsonographicevaluationshouldpromptthecliniciantoconsiderthepresenceofpulmonaryedemaandinitiateappropriatetreatment B lines Step3 EvaluationofthePipes Ruptureofthepipes aorticaneurysmanddissection Cloggingofthepipes venousthromboembolism AAA Ameasurementofgreaterthan3cmisabnormalanddefinesanabdominalaorticaneurysm AorticDissection Theparasternallong axisviewoftheheartpermitsanevaluationoftheproximalaorticroot andameasurementofmorethan3 8cmisconsideredabnormal AorticDissection Cloggingofthepipes venousthromboembolism Summary 病例2 24岁女性 58公斤 既往健康 仅口服避孕药 因 晕倒 被急救车送入院 病人意识模糊 病史有限 GCS 格拉斯哥昏迷评分 5 6 BP73 42 脉搏80次 分 体温38 3 SpO292 在吸氧4升 分钟的情况下 呼吸26次 分 大汗 右小腿及脚部明显肿胀 胸片无明显异常 心电图 窦性心律 血糖4 3mM L 急诊超声评估结果 1 心脏收缩力好 未见明显心包积液 无右室劳损表现 下腔静脉直径50 无浆膜腔积液主动脉正常 下肢静脉未见血栓