重症超声的临床应用

重症超声的临床应用,郭凤梅东南大学附属中大医院重症医学科,重症超声的临床应用,重症患者病情危重 有创操作多 易于发生病情变化，需要及 时发现、判断和处理 超声便捷、无创、及时、可重复、可视 床旁超声走向重症患者,重症超声的临床应用,循环功能和容量状态判断：复苏超声 肺部超声：Blue流程 血管定位和穿刺： 创伤的快速探查 气道评估和定位,Echocardiography is now an unavoidable tool in assessing hemodynamic instability in the ICU. Echocardiography training is crucial to help its widespread use in all ICUs.,休克复苏超声,Case 1,72yr，男性， 因发热、咳嗽伴胸痛就诊 BP 82/60mmHg, HR 120次/分, RR 24次/分,T 38.6, SpO2 92% 双肺底细湿罗音心电图左束支传导阻滞 胸片：双下肺少量渗出 无气胸、纵隔增宽和心影增大,5,Case 2,64yr，女性，气促伴胸痛入院 既往有乳腺癌病史，近三年稳定 T 98F, Bp74/58 mmHg , HR120次/分, RR30 次/分，SpO2 94% 颈静脉充盈，心音减低，双肺底少量湿罗音 EKG：低电压 胸片：心影增大、双肺散在渗出影,6,Discussion,ShockCase 1：重症肺炎，感染性休克ACS？肺栓塞？主动脉夹层？补液量？容量反应性？Case 2：心包填塞，梗阻性休克心包穿刺？肺栓塞？溶栓？,7,血流动力学监测 影像学检查,Discussion,Bedside Ultrasound,Bedside Ultrasound in Resuscitation and The Rapid Ultrasound In Shock Protocol (RUSH),Emergency Medicine Clinics of North America , 2010(28): 2956Ultrasound Clinics, 2012(7): 255278,8,休克复苏的超声应用,心脏泵功能容量状态,Critical Care Research and Practice, 2012,9,The pump： Cardiac status,A goal-directed echocardiogram: A：Left ventricular contractility B：Right ventricular dilatio C：Pericardial effusion,10,A：left ventricular contractility,Good left ventricular contractility,Fractional shortening=(EDD ESD)/EDD 10030%45% FS correlates to normal EF,Academic Emergency Medicine, 2011: 912921,11,Poor left ventricular contractility,12,Global left ventricular hypokinesia is very frequentin adult septic shock and could be unmasked, in some patients, by norepinephrine treatment (the overall incidence of global LV hypokinesia was 60%).,LVFAC 24%,Crit Care Med 2008; 36:17011706,左心收缩功能定性评价,节段性室壁运动异常,室壁瘤的形成,RV enlargement: dysfunctionSmall changes in pressure result in large changes in ventricular volume left-to-right Ventricleis 1 : 0 .6,B：right ventricular dilation,Eur Heart J 1996;17:77986.,15,B：right ventricular dilation,16,C：Signs of tamponade,17,C：pericardial effusions,Subxiphoid cardiac viewLeft image: typical effusion, right image: clotted effusion,18,RUQ free fluid. Coronal view of the RUQshowing free fluid,LUQ free fluid. Coronal view of the LUQfree fluid surrounding the spleen,19,Pelvic free fluidFree fluid in the rectovesicular space,20,A：Fullness of the Tank,A position approximately 2cm from the junction of the right atrium and the IVC,I VC diameter 50% with sniff CVP 3 mmHg ( range 0 5 mmHg),Journal of the American Society of Echocardiography , 2010, 23: 685713,21,A larger IVC 2 cm that collapses