2014-重症超声的临床应用

1、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

2、 to help its widespread use in all ICUs.,休克复苏超声,5,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,6,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

3、肺散在渗出影,7,Discussion,Shock Case 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？,8,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): 2956 Ult

4、rasound Clinics, 2012(7): 255278,9,休克复苏的超声应用,心脏泵功能 容量状态,Critical Care Research and Practice, 2012,10,The pump： Cardiac status,A goal-directed echocardiogram: A：Left ventricular contractility B：Right ventricular dilatio C：Pericardial effusion,11,A：left ventricular contractility,Good left ventricular

5、contractility,Fractional shortening=(EDD ESD)/EDD 100 30%45% FS correlates to normal EF,Academic Emergency Medicine, 2011: 912921,12,Poor left ventricular contractility,Global left ventricular hypokinesia is very frequent in adult septic shock and could be unmasked, in some patients, by norepinephri

6、ne 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,15,RV enlargement: dysfunction Small changes in pressure result in large changes in ventricular volume left-to-right Ventricleis 1 : 0 .6,B：right ventricular d

7、ilation,Eur Heart J 1996;17:77986.,16,B：right ventricular dilation,17,C：Signs of tamponade,18,C：pericardial effusions,Subxiphoid cardiac view Left image: typical effusion, right image: clotted effusion,19,RUQ free fluid. Coronal view of the RUQ showing free fluid,LUQ free fluid. Coronal view of the

8、LUQ free fluid surrounding the spleen,20,Pelvic free fluid Free fluid in the rectovesicular space,21,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 Echo

9、cardiography , 2010, 23: 685713,22,A larger IVC 2 cm that collapses50% with sniff suggests a high CVP pressure of 15 mmHg,Journal of the American Society of Echocardiography , 2010, 23: 685713,23,Intubated patients, the IVC becomes larger and less compliant,24,Echocardiographic indices of volume res

10、ponsiveness,Intensive Care Med, 1995, 21: 291295 Chest, 1999, 116: 13541359 Chest, 2001, 119: 867873,超声对容量状态的评估 -低血容量乳头肌亲吻征,包括9个相关研究，其中6个研究应用了超声技术,Intensive Care Med, 2010, 36:14751483,27,Focused Assessment of Sonography for Trauma (FAST ) Hemoperitoneum Hemothorax Ruptured ectopic pregnancy,Leakine

11、ss of the Tank,28,RUQ free fluid. Coronal view of the RUQ showing free fluid,LUQ free fluid. Coronal view of the LUQ free fluid surrounding the spleen,29,Pelvic free fluid Free fluid in the rectovesicular space,肺部超声,Pneumothorax,Interstitial syndrome,Alveolar consolidation,Pleural effusion,The pleur

12、al line is drawn by only the parietal pleura - there is pure air behind the pleural line. This yields A lines. The absence of visceral pleura yields absence of dynamic, yielding the stratosphere sign.,Normal lung surface: the dynamic of the pleura generates lung sliding. The normal subpleural interl

13、obular septa are too fine for generating B lines - the visceral pleura contains a layer of cells, i.e., mainly, fine contents of fluid.,Thickened subpleural interlobular septa which are surrounded by alveolar air. The beam is trapped in this small system including minime quantity of fluid (dimension

14、s inferior to that of ultrasound resolution) between alveolar air. This generates B lines.,Numerous alveoli are filled with fluid (transudate, exsudate, pus, .). The (deep) interlobular septa are here surrounded by fluid (comet-tail artifacts cannot be generated). The septa generate interfaces resul

15、ting in a tissue-like pattern.,The two layers of the pleura are separated by free fluid - resulting in homogeneous pattern (often anechoic). Note the regular lung line,air,air,air,air,air,air,air,(Air-fluid ratio) AIR/no fluid AIR/fluid AIR/fluid air/FLUID no air/FLUID 1 0.98 0.95 0.2 0,Normal lung

16、surface Athma COPD,正常肺超声,胸膜滑动，lung sliding,A线,蝙蝠征,胸膜线,二维超,M超,海岸征：Seashore sign,lung pulse,肺水肿时超声影像,air,air,air,B线,B线7个特征: 起源于胸膜线 高回声影像表现 容易发现 分布范围广 随呼吸节律移动 相应区域A线消失 慧尾征型伪像,超声波,肺实变的超声特征,肺泡内充填渗出液、脓液等 超声影像：实质性器官样改变,胸腔积液的超声影像,肺部病变超声-Interstitial syndrome,B+ lines: Three or more B lines in a single view,

17、Pleural effusion and alveolar consolidation; typical example of PLAPS (Posterolateral alveolar and/or pleural syndrome ),The quad sign, The sinusoid sign; The shred sign,气胸时超声影像,A线,蝙蝠征,M超：Stratosphere sign,胸膜线,气胸超声确诊：肺点(Lung Point),气胸诊断流程,(1)除外气胸征象： 可见胸膜线及胸膜滑动征 可见海岸征 可见lung pulse 可见B线 (2)怀疑气胸 胸膜滑动征消

18、失 M超显示平流征 (3)与气胸征象鉴别的其他情况 皮下气肿 胸膜粘连 肺气肿 肺顺应性显著降低 (4)确诊气胸 看到肺点,41,Sensitivities : 86% to 100 Specificities : 92% to 100% The average time: ultrasound was 2.3 minutes chest radiography 19.9 minutes,超声与平片诊断气胸的比较,Crit Care 2006;10:R112.,BLUE: Bedside Lung Ultrasound in Emergency,重症超声在肺部疾病中的诊断流程,血管穿刺置管超声

19、,常规体表定位法,疾病导致的解剖畸形 体位受限,血管解剖变异,右侧颈内静脉和动脉的解剖关系,1%,4.5%,22.5%,49.8%,22.2%,置管并发症,动脉损伤、局部血肿、严重出血 气胸、血胸 神经损伤 胸导管损伤 感染 ,方 式,超声引导的导管置入术（Ultrasound-guided cannulation） 超声辅助的导管置入术（Ultrasound-assisted cannulation） 超声确认血管内导管的位置（Ultrasound verification of intravascular placement）,确定静脉的方法,V管壁薄，容易被压迫 A管壁厚，有弹性，不容易被压迫,V和A彩色多普勒,探头按压,超声横断面引导法和纵段面引导法,颈内静脉短轴图像,颈内静脉长轴图像,横断面引导法 （平面外引导法）,纵断面引导法 （平面内引导法）,Short-axis,Long-axis,注意：穿刺时针头路径；针头压迫后静脉塌陷；容易直接穿进动脉内,探头无菌 探头支架，控制进针方向 减少压迫导致的血管塌陷,超声引导下纵断面穿刺法（平面内）,定位目标血管 寻找截面积最大的平面（截面是血管中间） 穿刺点位于靠近探头的皮肤 穿刺时移动针尖而不是移动探头 必须保证血管一直在屏幕上,超声引导下横断面穿