Post on 15-Feb-2019
Americo Testa americotesta@gmail.com
Università Cattolica del Sacro Cuore
Facolta’ di Medicina e Chirurgia
ROMA
Scuola di Ecografia Clinica
in Urgenza, D.E.A.
U.C.S.C - ROMA
Dipartimento di Emergenza ed Accettazione POLICLINICO UNIVERSITARIO “A. GEMELLI “
L.go A. Gemelli, 8 – ROMA www.ecourgenza.com
Scuola S.I.M.E.U.
di Ecografia Clinica in
Emergenza-Urgenza
Scuola Specialistica
S.I.U.M.B.
di Ecografia in
Emergenza-Urgenza
ECOGRAFIA CLINICA IN EMERGENZA – URGENZA
APPROCCIO BASE
MASTER EMERGENZE PEDIATRICHE UNIVERSITA’ “LA SAPIENZA” di ROMA
Roma, 20 Aprile 2012
L’ECOGRAFIA CLINICA INTEGRATA
NELL’ARRESTO CARDIACO
ARRESTO CARDIACO
“Il giorno dopo”, 1894/95. Olio su tela, Oslo. Edvard Munch
ALGORITMO ALS PER ARRESTO CARDIACO
Non riponde?
Apri le vie aeree
Cerca segni di vita
RCP 30:2
Fino al collegamento del monitor/defibrillatore
Valuta il ritmo
Defibrillabile
(FV/TV senza polso)
Non defibrillabile
(PEA/Asistolia)
1 Shock 150-200 J bifasico
o 360 monofasico
Ricomincia RCP 30:2 per 2 min Ricomincia RCP 30:2 per 2 min
Considera cause reversibili: 4I e 4T
Ecografia nelle pause
1. “ Minimal interruption of CPR to reduce the no-flow intervals ”
2. “ Identification and Treatment of reversible causes ”
Nolan JP et al. Resuscitation 67: S39-S86, 2005
Hazinski MF et al. Circulation 112: 206-211, 2005
Christenson J et al. Circulation 120:1241-1247, 2009
J.P. Nolan et al. Resuscitation 81:1219–1276, 2010
2005-2010 ERC (ALS) / AHA guidelines (ACLS)
recommend:
L’ECOGRAFIA NELL’ARRESTO CARDIACO
La “Emergency US” non ostacola la RCP
Breitkreutz R et al. Crit Care Med 35:S150-161, 2007
Hayhurst C et al. Emerg Med J 28:119.121, 2011
1. “Minimal interruption of CPR to reduce the no-flow intervals”
L’ECOGRAFIA NELL’ARRESTO CARDIACO
2. “Identification and Treatment of reversible causes”
La “Emergency US” identifica le cause
reversibili di ACC e guida il trattamento
4 I Ipovolemia
Ipotermia
Ipossia
Ipo- iperpotassiemia
4T Tamponamento cardiaco
PneumoTorace iperteso
Tromboembolia polmonare / coronarica
Tossici
Quali cause reversibili sono indagabili con US?
Hughes S and McQuillan PJ. Resuscitation 37: 51, 1998
Hernandez C et al.. Resuscitation 76:198-206, 2008
L’ECOGRAFIA NELL’ARRESTO CARDIACO
“…ultrasound may be of use in assisting with diagnosis
and treatment of potentially reversible causes of cardiac
arrest.”
pp. 1234-1235
“ Use of ultrasound imaging during advanced life support”
Rani Robson (Editorial). Resuscitation 81:1453-1454, 2010.
Use of US to detect and treat reversible causes during CPR Sir,
We agree with Dr. Sloth and colleagues that ultrasound (including cardiac
echocardiography) can have a useful role for identifying and treating reversible causes
of cardiac arrest. The use of ultrasound is already recommended in the current
guidelines to help treatment of cardiac arrest in certain ‘special’ circumstances.
Soar J, Nolan JP (Letter). Resuscitation doi: 10.1016/j.resuscitation.2007.03.005
Echocardiography during CPR: more studies needed
Echocardiography during ALS is a promising advance in resuscitation care.
However, further studies are needed to help clarify the true value and praticality of
ecochardiography in cardiac arrest patients.
Its use during CPR appears to be useful in expert hands.
Blaivas M., Fox JC. Academic Emergency Medicine 8:616–621, 2001
L’ECOGRAFIA NELL’ARRESTO CARDIACO
“Cardiac contractile activity visualized on bedside US may be used as prognostic factor in cardiac arrest”
Immediate subxiphoid or parasternal cardiac ultrasound examination by EP
plus brief repeat US examination during the CPR when pulses were checked.
Cardiac standstill on US resulted in a positive predictive value of 100% for
death in the ED, with a negative predictive value of 58%.
It may be an additional marker for cessation of resuscitative efforts.
169 out-of-hospital pts with cardiac arrest:
65/169 had asystole, 38/169 had PEA and 66/169 had VF.
136/169 without wall motion on US: no survived
33/169 with wall motion on US: 20/33 survived.
Salen P et al. Acad Emerg Med 8:610-615, 2001
Tayal VS, Kline JA. Resuscitation 59:315-318, 2003
Schuster KM et al.. J Trauma 67:1154-1157, 2009
L’ECOGRAFIA NELL’ARRESTO CARDIACO
“Cardiac contractile activity visualized on bedside US may be used as prognostic factor in cardiac arrest after trauma”
The pericardial view of the FAST can differentiate between patients with and
without organized cardiac activity and may assist in the decision to terminate
ongoing resuscitation.
Bedside US may identify those patients with potential for survival.
28 pts presenting to a trauma center who had PEA:
12/28 patients had contractile cardiac activity on US;
3/12 survived, with tension pneumothorax, tension hemothorax, and
hypovolemia.
Varriale P and Maldonado JM. Crit Care Med 25:1717-1720, 1997
Hayhurst C et al. Emerg Med J 28:119.121, 2011
Prosen G et al. J Intern Med Res 38:1458-1467, 2010
Breitkreutz R et al. Resuscitation 81:1527-1533, 2010
L’ECOGRAFIA NELL’ARRESTO CARDIACO
“It may not be an additional marker for cessation of resuscitative efforts.
Lack of cardiac motion on single10 sec evaluation alone is not a reliable
indication to stop CRP (NPV of 97% for predicting ROSC) .
On the other hand, vigorous cardiac motion is a powerful reason to
continue CRP (PPV of 55% for predicting ROSC).
ECoCG verification of a pseudo-PEA state enabled additional treatment
and cessation of chest compressions. It is associated to high rate of
ROSC (15/16 = 94%).
Initial lack of cardiac motion in 18/20 patients: it returned in 4/18, of
whom 2 survived.
ECHOCARDOGRAPHIC observation in conjunction with
conventional CPR in 20 in-hospital patients.
Varriale P and Maldonado JM. Crit Care Med 25:1717-1720, 1997
L’ECOGRAFIA NELL’ARRESTO CARDIACO
“Many of the conditions underlying PEA are associated with specific cardiac US findings”
PORTABLE echocardiographic system and alerted CARDIOLOGY
team skilled in this technique.
ECHOCARDOGRAPHIC examination feasible during CPR and may
depict the cause of cardiac arrest: PULMONARY EMBOLISM,
CARDIAC TAMPONADE and HYPOVOLEMIA.
Focused
Assessed
Transthoracic
Echocardiography
Jensen MB et al. Eur J Anaesthesiol 21:700-707, 2004
ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND
DURING CARDIAC ARREST
L’ECOGRAFIA NELL’ARRESTO CARDIACO
Niendorff DF et al. Resuscitation 67:81-87, 2005
ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND
DURING CARDIAC ARREST
“Rapid cardiac ultrasound (subcostal view) of
inpatients suffering PEA arrest performed by
nonexpert sonographers”
“Focused cardiac ultrasound (3 standard views) in
cardiac arrest performed by non cardiologist”
Jensen MB et al. Eur J Anaesthesiol 21:700-707, 2004
L’ECOGRAFIA NELL’ARRESTO CARDIACO
Focused
Assessed
Transthoracic
Echocardiography
Price S et al. Resuscitation 81:1534-1539, 2010.
Effectiveness of a standardised one-day training course
designed to be the first step to deliver ALS-compliant
Ecochardiography skills.
All 41 students obtained a subcostal view of diagnostic
quality, with acquisition in less than 10 sec during
rhythm checks in 86% of cases.
“Nonexpert sonographers”
Focused
Assessment with
Sonography for
Trauma,
Cardiac arrest / failure,
Respiratory arrest / failure,
Acute abdomen and
Shock and Hypotension
Cibinel GA. Ecografia Clinica in Emergenza-Urgenza. C.G. Edizioni Medico Scientifiche, 2005
ALGORITHMIC APPROACH FOR THE USE OF
ULTRASOUND DURING CARDIAC ARREST
L’ECOGRAFIA NELL’ARRESTO CARDIACO
FAST-CRASH
IMPATTO DIAGNOSTICO E TERAPEUTICO
Cibinel GA et al. VI Congresso Nazionale SIMEU, 12- 16 Nov. 2008, Atti p.141
30 pazienti: 14 in ACC e 16 in Periarresto
FATTIBILITA’: 100% dei casi senza interferenza con manovre rianimatorie.
IMPATTO DIAGNOSTICO: nel 63% dei casi diagnosi grazie ad ecografia tra cui 7 EP, 1 Tamponamento, 2 IMA, 3 Ipovolemia, 1 PNX etc.
IMPATTO TERAPEUTICO: 43% dei casi terapia grazie ad ecografia tra cui 6 trombolisi, 1 pericardiocentesi, 2 fluidi, 1 drenaggo toracico, 2 sospensioni massaggio etc. + 30% manovre interventistiche eco-guidate.
L’ECOGRAFIA NELL’ARRESTO CARDIACO
Focused
Echocardiographic
Evaluation in
Resuscitation management
Breitkreutz R et al. Crit Care Med 35:S150-161, 2007
ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND
DURING CARDIAC ARREST
L’ECOGRAFIA NELL’ARRESTO CARDIACO
ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND
DURING CARDIAC ARREST
Focused
Echocardiographic
Evaluation in
Life support
Breitkreutz R et al. Resuscitation 81:1527-1533, 2010
L’ECOGRAFIA NELL’ARRESTO CARDIACO
Focused
Echocardiographic
Evaluation in
Resuscitation management
Breitkreutz R et al. Crit Care Med 35:S150-161, 2007
Patients: 77 out-of-hospital CPR cases, 30 with suspected PEA.
FEER Protocol
DIAGNOSTIC AND THERAPEUTIC IMPACT
Methods: developed an algorythm to obtain an EcoCG within 5 sec pause of CPR with Subcostal long axis 4chamber view, alternatively with Parasternal short and/or long axis or Apical 4 chamber view
Results:
Accuracy: 19/30 cases: pseudo-PEA. Detected cardiac wall movement (3 pericardial tamponade, 14 poor ventricolar function, 2 hypovolemia): 13/19 survived.
11/30 cases: true PEA, with true cardiac standstill:
all died.
Therapy: FEER based changes in 24/30 cases.
L’ECOGRAFIA NELL’ARRESTO CARDIACO
Focused
Echocardiographic
Evaluation in
Life support
Conclusion: Application of FEEL in pre-hospital care is feasible, and alters diagnosis and management in a significant number (78%) of patients.
FEEL Protocol
DIAGNOSTIC AND THERAPEUTIC IMPACT
Results: 88/230 patients had a suspected PEA or asystole.
Feasibility: images of diagnostic quality were obtained in 96%.
Incidence of potentially treatable conditions:
51/88 PEA, 13/51 without wall motion (1 survived) e 38/51 with wall motion (21 survived);
37/88 asystole, 24/37 without wall motion (4 survived) e 13/37 with wall motion (9 survived);
L’ECOGRAFIA NELL’ARRESTO CARDIACO
Patients: prospective observational study in a pre-hospital emergency setting.
Breitkreutz R et al. Resuscitation 81:1527-1533, 2010
Cardiac
Arrest
Ultra
Sound
Examen
Hernandez C et al.. Resuscitation 76(2):198-206, 2008
ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND
DURING CARDIAC ARREST
L’ECOGRAFIA NELL’ARRESTO CARDIACO
Cardiac
Arrest
Ultra
Sound
Examen
It reasserts the use of THORACIC other than classic CARDIAC scans
to look for the most common and easily reversible underlying
causes, including TENSION PNEUMOTHORAX.
Conclude that the C.A.U.S.E. protocol reduces the time required to
determine the etiology of a cardiac arrest and the time between arrest
and the time therapy
L’ECOGRAFIA NELL’ARRESTO CARDIACO
CAUSE Protocol
DIAGNOSTIC AND THERAPEUTIC IMPACT
Hernandez C et al.. Resuscitation 76(2):198-206, 2008
Echo in
Life
Support
Hayhurst C et al. Emerg Med J 28:119.121, 2011
ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND
DURING CARDIAC ARREST
L’ECOGRAFIA NELL’ARRESTO CARDIACO
L’ECOGRAFIA NELL’ARRESTO CARDIACO
ELS
Is it feasible? What does it add?
Echo in
Life
Support
Hayhurst C et al. Emerg Med J 28:119.121, 2011
Patients: ELS was performed on 50 patients during CA with subxiphoid, parasternal, apical or combined view: 7 traumatic e 43 non-traumatic
Results: 43/50 patients had a suspected PEA or asystole.
Feasibility: adequate views obtained in 97%, within the 10 sec rhythm check in 90%.
Incidence of potentially treatable conditions:
20/50 (40%) with wall motion (1 survived) e 38/51 with wall motion (21 survived);
3/50 (6%) with pericardial effusion;
Management: 7/50 (14%) treated as result of ELS (thrombolysis, insert of chest drain and pericardiocentesis).
Pulmonary
Epigastric
Abdominal
ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND
DURING CARDIAC ARREST
L’ECOGRAFIA NELL’ARRESTO CARDIACO
Testa A et al. Eur Rev Med Pharmacol Sci 14:77-88, 2010
Approccio con 3 sequenze di scansioni mirate (“focused o goal-directed”)
su Cuore, Polmoni, Addome e Arti
ARRESTO CARDIACO: “PEA protocol”
Pulmonary
scans (Pneumothorax, pleural
effusion, wet or dry lung)
Epigastric
and other scans (Tamponade, IVC,
heart sides and motion)
Abdominal
and other scans (Aorta, bowel occlusion,
abdominal effusion, DVT)
Testa A et al. Eur Rev Med Pharmacol Sci 14:77-88, 2010
Epigastric
and other scans (Tamponade, IVC,
heart sides and motion)
SCANSIONI FONDAMENTALI “Il cuore è come LA SCATOLA NERA di un aereo”:
Meglio non aspettare ad aprirla per vedere cosa
non ha funzionato!!!
Hayhurst C et al. Emerg Med J 28:119.121, 2011
Goals of the focused cardiac US:
1. PEA vs pseudoPEA;
2. the assessment for pericardial effusion;
3. the RV enlargement/dysfunction;
4. global cardiac LV systolic function;
5. patient volume status.
J Am Soc Echocardiogr 2010;23:1225-30.
Epigastric
and other scans (Tamponade, IVC,
heart sides and motion)
SCANSIONI
FONDAMENTALI
1. Cuore fermo
(PEA)
Epigastric
and other scans (Tamponade, IVC,
heart sides and motion)
SCANSIONI
FONDAMENTALI
4. Tamponamento cardiaco
Epigastric
and other scans (Tamponade, IVC,
heart sides and motion)
SCANSIONI
FONDAMENTALI
5. Embolia polmonare
Epigastric
and other scans (Tamponade, IVC,
heart sides and motion)
SCANSIONI
FONDAMENTALI
2. Cuore ipocinetico
Epigastric
and other scans (Tamponade, IVC,
heart sides and motion)
SCANSIONI
FONDAMENTALI
3. Cuore piccolo ipercinetico
Epigastric
and other scans (Tamponade, IVC,
heart sides and motion)
SCANSIONI
FONDAMENTALI
Riempimento VCI
Sì Gliding = Normale
Pulmonary
scans (Pneumothorax, pleural
effusion, wet or dry lung)
NO Gliding = PNX
SCANSIONI
COMPLEMENTARI
Tendina Normale
Pulmonary
scans (Pneumothorax, pleural
effusion, wet or dry lung)
Versamento
SCANSIONI
COMPLEMENTARI
Normale Wet lung
Pulmonary
scans (Pneumothorax, pleural
effusion, wet or dry lung)
SCANSIONI
COMPLEMENTARI
SCANSIONI
SUPPLEMENTARI
Comprimibile= Normale NON Comprimibile=TVP
Abdominal
and other scans (Aorta, bowel occlusion,
abdominal effusion, DVT)
CUS CUS
STOP
CPR ?
Not running
Ectasic IVC
P
E
A TRUE PEA
STOP
CPR ?
Not running
Ectasic IVC
Wet lung
Hypokinetic
Ectasic IVC
THROMBO-
LISIS / PTCA
P
E
A MYOC. INSUFFIC.
Small effusion
Smal effusion
TRUE PEA
STOP
CPR ?
Not running
Ectasic IVC
Wet lung
Hypokinetic
Ectasic IVC Flat IVC
Normal lung
THROMBO-
LISIS / PTCA
HYPOVOLEMIA
P
E
A
Empty hyperkinetic
VOLUME
REPLACEMENT
MYOC. INSUFFIC.
Small effusion
Occlusion
Small effusion
Normal pleura
TRUE PEA
STOP
CPR ?
Not running
Ectasic IVC
Wet lung
Hypokinetic
Ectasic IVC
Normal lung Normal lung
Ectasic IVC
THROMBO-
LISIS / PTCA
HYPOVOLEMIA TAMPONADE
P
E
A
Effusion
PERICARDIO-
CENTESIS
VOLUME
REPLACEMENT
MYOC. INSUFFIC.
Small effusion
Occlusion TAA
Smal effusion
Normal pleura Normal pleura
TRUE PEA
Empty hyperkinetic
Flat IVC
STOP
CPR ?
Not running
Ectasic IVC
Wet lung
Hypokinetic
Ectasic IVC
Normal lung Normal lung
Ectasic IVC Ectasic IVC
Large RV
Normal lung
THROMBO-
LISIS / PTCA
HYPOVOLEMIA TAMPONADE
P
E
A
Effusion
PULM. EMBOL.
THROMBO-
LYSIS PERICARDIO-
CENTESIS
VOLUME
REPLACEMENT
MYOC. INSUFFIC.
Small effusion
Occlusion TAA DVT
Smal effusion
Normal pleura Normal pleura Normal pleura
TRUE PEA
Empty hyperkinetic
Flat IVC
STOP
CPR ?
Not running
Ectasic IVC
Wet lung
Hypokinetic
Ectasic IVC
Normal lung Normal lung
Ectasic IVC Ectasic IVC
Large RV
Normal lung No gliding
Normal
Ectasic IVC
THROMBO-
LISIS / PTCA
HYPOVOLEMIA TAMPONADE
THORACIC
DRAINAGE
PNEUMOTHORAX
P
E
A
Effusion
PULM. EMBOL.
THROMBO-
LYSIS PERICARDIO-
CENTESIS
VOLUME
REPLACEMENT
MYOC. INSUFFIC.
Small effusion Normal pleura
Occlusion TAA DVT Normal abdomen
Smal effusion
Normal pleura Normal pleura Normal pleura
TRUE PEA
Empty hyperkinetic
Flat IVC
The “Emergency US” integrata nella gestione ABCDE del paziente
critico (periarresto, arresto, post-ROSC): la FAST-ABCDE
A=Airway Assistenza alla tracheostomia.
Controllo malposizione tubo oro-tracheale.
B=Breath Ricerca di PNX iperteso.
Assistenza a decompressione con ago / drenaggio PNX.
C=Circulation Ricerca di emotorace, emopericardio ed emoperitoneo.
Assistenza a toracentesi / pericardiocentesi.
Assistenza ad accesso venoso periferico o centrale.
Performance cardiaca e riempimento VCI.
D=Disability Pressione endocranica da nervo ottico.
E=Exposure Fratture sternali, costali. Contusioni. PNX minimo.
Ricerca di lesioni parenchimali organi addominali.
Lesioni tessuti molli superficiali.
Blocco anestetico loco-regionale.
Neri L, Storti E, Lichtenstein D. Crit Care Med, 35: S290-S304, 2007.
-NB: L’esame ecografico in urgenza è uno strumento diagnostico accessorio mirato al quesito clinico,
pertanto con valore limitato, e non sostituisce l’esame ecografico in elezione.
-Dr. Mario Rossi 1234
L’ECOGRAFIA CLINICA IN EMERGENZA - URGENZA
Testa A. Manuale di Ecografia Clinica in Urgenza. Verduci Editore, Roma, 2008
Referto
-Ecografia eseguita in urgenza, mirata alla valutazione clinica integrata in paziente in arresto cardiaco: -Esame tecnicamente adeguato.
-Esito: -Attività cardiaca rilevata. Non versamento pericardico tamponante. Sezioni destre non prevalenti, cinesi conservata. VS con funzione contrattile non compromessa. Camere normo-dilatate. non ectasica e responsiva a dinamica respiratoria. VCI
Non segni di PNX. Non versamento pleurico. Non segni di s. interstiziale bilateralmente.
Non ectasia aorta toracica/addominale. Non versamento endoperitoneale o segni
di occlusione/perforazione. Non segni di trombosi venosa a carico degli assi
venosi profondi. -Commenti e rilievi collaterali: nessuno.
Cibinel GA. Corso Eco-ALS, SIMEU. Pinerolo (To), 2007.
“ERC chain of survival”…
Aggiunta degli US nel 3° anello
Sloth E et al. Resuscitation 74(1):198-199.2007
“ERC chain of survival”…
Aggiunta di un 5° anello con US
Perché restare ciechi…
“Among the BLIND, the ONE-EYED man is KING” (Erasmo da Rotterdam)
… quando si può lavorare protetti?
Vi ringrazio per l’attenzione.
BUON LAVORO