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Advanced Hemodynamic and Cardiopulmonary Ultrasound for Critically Ill Patients in the Emergency Department

Emergency Medicine. 2018 January;50(1):17-34 | 10.12788/emed.2018.0078

References

1. Kanji HD, McCallum J, Sirounis D, MacRedmond R, Moss R, Boyd JH. Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes. J Crit Care. 2014;29(5):700-705. doi:10.1016/j.jcrc.2014.04.008.

2. Raja AS, Jacobus CH. How accurate is ultrasonography for excluding pneumothorax? Ann Emerg Med. 2013;61(2):207-208. doi:10.1016/j.annemergmed.2012.07.005.

3. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and analysis. Chest. 2012;141(3):703-708. doi:10.1378/chest.11-0131.

4. Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005;12(9):844-849. doi:10.1197/j.aem.2005.05.005.

5. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest. 2011;139(5):1140-1147.

6. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004;100(1):9-15.

7. Xirouchaki N, Magkanas E, Vaporidi K, et al. Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med. 2011;37(9):1488-1493. doi:10.1007/s00134-011-2317-y.

8. Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care. 2014;4(1):1.

9. Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33(6):1231-1238.

10. Slater A, Goodwin M, Anderson KE, Gleeson FV. COPD can mimic the appearance of pneumothorax on thoracic ultrasound. Chest. 2006;129(3):545-550. doi:10.1378/chest.129.3.545.

11. Lichtenstein DA, Lascols N, Prin S, Mezière G. The “lung pulse”: an early ultrasound sign of complete atelectasis. [published online ahead of print October 14, 2003]. Intensive Care Med. 2003;29(12):2187-2192. doi:10.1007/s00134-003-1930-9.

12. Lichtenstein D. Fluid administration limited by lung sonography: the place of lung ultrasound in assessment of acute circulatory failure (the FALLS-protocol). Expert Rev Respir Med. 2012;6(2):155-162. doi:10.1586/ers.12.13.

13. Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med. 1998;24(12):1331-1334.

14. Dickman E, Terentiev V, Likourezos A, Derman A, Haines L. Extension of the thoracic spine sign: a new sonographic marker of pleural effusion. [published online ahead of print August 12, 2015]. J Ultrasound Med. 2015;34(9):1555-1561. doi:10.7863/ultra.15.14.06013.

15. Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJ, Liteplo A. Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. [published online ahead of print February 2, 2009]. Chest. 2009;135(6):1433-1439. doi:10.1378/chest.08-1811.

16. Lichtenstein D. Lung and Interstitial Syndrome. In: Lichtenstein D, ed. Whole Body Ultrasonography in the Critically IIl. New York, NY: Springer; 2010:151-157.

17. Lichtenstein DA, Mezière GA, Lagoueyte JF, Biderman P, Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest. 2009;136(4):1014-1020. doi:10.1378/chest.09-0001.

18. Romero-Bermejo FJ, Ruiz-Bailen M, Gil-Cebrian J, Huertos-Ranchal MJ. Sepsis-induced cardiomyopathy. Curr Cardiol Rev. 2011;7(3):163-183.

19. Sanfilippo F, Corredor C, Fletcher N, et al. Diastolic dysfunction and mortality in septic patients: a systematic review and meta-analysis. [published online ahead of print March 24, 2015]. Intensive Care Med. 2015;41(6):1004-1013. doi:10.1007/s00134-015-3748-7.

20. Randazzo MR, Snoey ER, Levitt MA, Binder K. Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med. 2003;10(9):973-977.

21. Reardon R. Cardiac. In: Ma O, Mateer J, eds. Emergency Ultrasound. 2nd ed. New York, NY: McGraw Hill Companies, Inc; 2008:114-115.

22. Martindale JL, Wakai A, Collins SP, et al. Diagnosing acute heart failure in the emergency department: a systematic review and meta-analysis. [published online ahead of print February 13, 2016]. Acad Emerg Med. 2016;23(3):223-242. doi:10.1111/acem.12878.

23. Cerqueira MD, Weissman NJ, Dilsizian V, et al; American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105(4):539-542.

24. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification. [published online ahead of print February 2, 2006]. Eur J Echocardiogr. 2006;7(2):79-108. doi:10.1016/j.euje.2005.12.014.

25. Secko MA, Lazar JM, Salciccioli LA, Stone MB. Can junior emergency physicians use E-point septal separation to accurately estimate left ventricular function in acutely dyspneic patients? [published online ahead of print November 1, 2011]. Acad Emerg Med. 2011;18(11):1223-1226. doi:10.1111/j.1553-2712.2011.01196.x.

26. Dinh VA, Ko HS, Rao R, et al. Measuring cardiac index with a focused cardiac ultrasound examination in the ED. [published online ahead of print July 12, 2012]. Am J Emerg Med. 2012;30(9):1845-1851. doi:10.1016/j.ajem.2012.03.025.

27. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355(3):251-259. doi:10.1056/NEJMoa052256.

28. Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009;22(2):107-133. doi:10.1016/j.echo.2008.11.023.

29. Ommen SR, Nishimura RA. A clinical approach to the assessment of left ventricular diastolic function by Doppler echocardiography: update 2003. Heart. 2003;89 Suppl 3:iii18-23.

30. Haddad F, Hunt SA, Rosenthal DN, Murphy DJ. Right ventricular function in cardiovascular disease, part I: anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation. 2008;117(11):1436-1448. doi:10.1161/CIRCULATIONAHA.107.653576.

31. Zochios V, Jones N. Acute right heart syndrome in the critically ill patient. Heart Lung Vessel. 2014;6(3):157-170.

32. Mekontso Dessap A, Boissier F, Charron C, et al. Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. [published online ahead of print December 9, 2015]. Intensive Care Med. 2016;42(5):862-870. doi:10.1007/s00134-015-4141-2.

33. Jardin F, Gueret P, Dubourg O, Farcot JC, Margairaz A, Bourdarias JP. Two-dimensional echocardiographic evaluation of right ventricular size and contractility in acute respiratory failure. Crit Care Med. 1985;13(11):952-956.

34. Dalabih M, Rischard F, Mosier JM. What’s new: the management of acute right ventricular decompensation of chronic pulmonary hypertension. [published online ahead of print September 3, 2014]. Intensive Care Med. 2014;40(12):1930-1933. doi:10.1007/s00134-014-3459-5.

35. Brennan JM, Blair JE, Goonewardena S, et al. Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr. 2007;20(7):857-861. doi:10.1016/j.echo.2007.01.005.

36. Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure. Circulation. 2008;117(13):1717-1731. doi:10.1161/CIRCULATIONAHA.107.653584.

37. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469-473.

38. Gajanana D, Seetha Rammohan H, Alli O, et al. Tricuspid annular plane systolic excursion and its association with mortality in critically ill patients. [published online ahead of print March 1, 2015]. Echocardiography. 2015;32(8):1222-1227. doi:10.1111/echo.12926.

39. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-713; quiz 786-788. doi:10.1016/j.echo.2010.05.010.

40. Vogel M, Schmidt MR, Kristiansen SB, et al. Validation of myocardial acceleration during isovolumic contraction as a novel noninvasive index of right ventricular contractility: comparison with ventricular pressure-volume relations in an animal model. Circulation. 2002;105(14):1693-1699.

41. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377. doi:10.1056/NEJMoa010307.

42. Peake SL, Delaney A, Bailey M, et al; ARISE Investigators, ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. [published online ahead of print October 1, 2014]. N Engl J Med. 2014;371(16):1496-1506. doi:10.1056/NEJMoa1404380.

43. Yealy DM, Kellum JA, Huang DT, et al; ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. [published online ahead of print March 18, 2014]. N Engl J Med. 2014;370(18):1683-1693. doi:10.1056/NEJMoa1401602.

44. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. [published online ahead of print March 17, 2015]. N Engl J Med. 2015;372(14):1301-1311. doi:10.1056/NEJMoa1500896.

45. Marik PE, Lemson J. Fluid responsiveness: an evolution of our understanding. [published online ahead of print February 16, 2014]. Br J Anaesth. 2014;112(4):617-620. doi:10.1093/bja/aet590.

46. Marik PE. Fluid Responsiveness and the Six Guiding Principles of Fluid Resuscitation. Crit Care Med. 2016;44(10):1920-1922. doi:10.1097/CCM.0000000000001483.

47. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39(2):259-265. doi:10.1097/CCM.0b013e3181feeb15.

48. Wiedemann HP, Wheeler AP, Bernard GR, et al; National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. [published online ahead of print May 21, 2006]. N Engl J Med. 2006;354(24):2564-2575. doi:10.1056/NEJMoa062200.

49. McGee S, Abernethy WB 3rd, Simel DL. The rational clinical examination. Is this patient hypovolemic? JAMA. 1999;281(11):1022-1029.

50. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41(7):1774-1781. doi:10.1097/CCM.0b013e31828a25fd.

51. Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007;35(1):64-68. doi:10.1097/01.CCM.0000249851.94101.4F.

52. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37(9):2642-2647. doi:10.1097/CCM.0b013e3181a590da.

53. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest. 2002;121(6):2000-2008.

54. Feissel M, Michard F, Faller JP, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. [published online ahead of print March 25, 2004]. Intensive Care Med. 2004;30(9):1834-1837. doi:10.1007/s00134-004-2233-5.

55. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172-178. doi:10.1378/chest.07-2331.

56. Nagdev AD, Merchant RC, Tirado-Gonzalez A, Sisson CA, Murphy MC. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. [published online ahead of print June 25, 2009]. Ann Emerg Med. 2010;55(3):290-295. doi:10.1016/j.annemergmed.2009.04.021.

57. Wallace DJ, Allison M, Stone MB. Inferior vena cava percentage collapse during respiration is affected by the sampling location: an ultrasound study in healthy volunteers. [published online ahead of print December 9, 2009]. Acad Emerg Med. 2010;17(1):96-99. doi:10.1111/j.1553-2712.2009.00627.x.

58. Blehar DJ, Resop D, Chin B, Dayno M, Gaspari R. Inferior vena cava displacement during respirophasic ultrasound imaging. Crit Ultrasound J. 2012;4(1):18. doi:10.1186/2036-7902-4-18.

59. Funk DJ, Jacobsohn E, Kumar A. The role of venous return in critical illness and shock-part I: physiology. Crit Care Med. 2013;41(1):255-262. doi:10.1097/CCM.0b013e3182772ab6.

60. Lansdorp B, Hofhuizen C, van Lavieren M, et al. Mechanical ventilation-induced intrathoracic pressure distribution and heart-lung interactions*. Crit Care Med. 2014;42(9):1983-1990. doi:10.1097/CCM.0000000000000345.

61. Barbier C, Loubières Y, Schmit C, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. [published online ahead of print March 18, 2004]. Intensive Care Med. 2004;30(9):1740-1746. doi:10.1007/s00134-004-2259-8.

62. Machare-Delgado E, Decaro M, Marik PE. Inferior vena cava variation compared to pulse contour analysis as predictors of fluid responsiveness: a prospective cohort study. J Intensive Care Med. 2011;26(2):116-124. doi:10.1177/0885066610384192.

63. Corl K, Napoli AM, Gardiner F. Bedside sonographic measurement of the inferior vena cava caval index is a poor predictor of fluid responsiveness in emergency department patients. [published online ahead of print September 7, 2012]. Emerg Med Australas. 2012;24(5):534-539. doi:10.1111/j.1742-6723.2012.01596.x.

64. Lanspa MJ, Grissom CK, Hirshberg EL, Jones JP, Brown SM. Applying dynamic parameters to predict hemodynamic response to volume expansion in spontaneously breathing patients with septic shock. Shock. 2013;39(2):155-160. doi:10.1097/SHK.0b013e31827f1c6a.

65. Muller L, Bobbia X, Toumi M, et al. Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Crit Care. 2012;16(5):R188. doi:10.1186/cc11672.

66. de Witt B, Joshi R, Meislin H, Mosier JM. Optimizing oxygen delivery in the critically ill: assessment of volume responsiveness in the septic patient. [published online ahead of print August 1, 2014]. J Emerg Med. 2014;47(5):608-615. doi:10.1016/j.jemermed.2014.06.015.

67. Monnet X, Rienzo M, Osman D, et al. Esophageal Doppler monitoring predicts fluid responsiveness in critically ill ventilated patients. [published online ahead of print July 30, 2005]. Intensive Care Med. 2005;31(9):1195-1201. doi:10.1007/s00134-005-2731-0.

68. Slama M, Masson H, Teboul JL, et al. Monitoring of respiratory variations of aortic blood flow velocity using esophageal Doppler. [published online ahead of print March 5, 2004]. Intensive Care Med. 2004;30(6):1182-1187. doi:10.1007/s00134-004-2190-z.

69. Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest. 2001;119(3):867-873.

70. Durand P, Chevret L, Essouri S, Haas V, Devictor D. Respiratory variations in aortic blood flow predict fluid responsiveness in ventilated children. [published online ahead of print February 8, 2008]. Intensive Care Med. 2008;34(5):888-894. doi:10.1007/s00134-008-1021-z.

71. Lewis JF, Kuo LC, Nelson JG, Limacher MC, Quinones MA. Pulsed Doppler echocardiographic determination of stroke volume and cardiac output: clinical validation of two new methods using the apical window. Circulation. 1984;70(3):425-431.

72. Muller L, Toumi M, Bousquet PJ, et al. An increase in aortic blood flow after an infusion of 100 ml colloid over 1 minute can predict fluid responsiveness: the mini-fluid challenge study. Anesthesiology. 2011;115(3):541-547. doi:10.1097/ALN.0b013e318229a500.

73. Lamia B, Ochagavia A, Monnet X, Chemla D, Richard C, Teboul JL. Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity. [published online ahead of print May 17, 2007]. Intensive Care Med. 2007;33(7):1125-1132. doi:10.1007/s00134-007-0646-7.

74. Maizel J, Airapetian N, Lorne E, Tribouilloy C, Massy Z, Slama M. Diagnosis of central hypovolemia by using passive leg raising. [published online ahead of print May 17, 2007]. Intensive Care Med. 2007;33(7):1133-1138. doi:10.1007/s00134-007-0642-y.

75. Monge García MI, Gil Cano A, Díaz Monrové JC. Brachial artery peak velocity variation to predict fluid responsiveness in mechanically ventilated patients. [published online ahead of print September 3, 2009]. Crit Care. 2009;13(5):R142. doi:10.1186/cc8027.

76. Blehar DJ, Glazier S, Gaspari RJ. Correlation of corrected flow time in the carotid artery with changes in intravascular volume status. [published online ahead of print April 2, 2014]. J Crit Care. 2014;29(4):486-488. doi:10.1016/j.jcrc.2014.03.025.

77. Mackenzie DC, Khan NA, Blehar D, et al. Carotid Flow Time Changes With Volume Status in Acute Blood Loss. [published online ahead of print May 21, 2005]. Ann Emerg Med. 2015;66(3):277-282.e1. doi:10.1016/j.annemergmed.2015.04.014.

78. Stolz LA, Mosier JM, Gross AM, Douglas MJ, Blaivas M, Adhikari S. Can emergency physicians perform common carotid Doppler flow measurements to assess volume responsiveness? [published online ahead of print February 26, 2015]. West J Emerg Med. 2015;16(2):255-259. doi:10.5811/westjem.2015.1.24301.

79. Marik PE, Levitov A, Young A, Andrews L. The use of bioreactance and carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients. Chest. 2013;143(2):364-370. doi:10.1378/chest.12-1274.

Consolidation

Chest radiography is known to have variable test characteristics for the detection of pneumonia. Consolidation may not be detected in profoundly immunocompromised or dehydrated patients. Additionally, in critically ill patients, it is often challenging to obtain a posteroanterior and lateral chest X-ray, given the patient’s hemodynamic status and stability for transport, and a single portable anteroposterior film will often miss retrocardiac infiltrates. In both of these clinical settings, POCUS can provide a rapid diagnosis, expediting the care of these septic patients.

In the presence of a dense consolidation, there may be hepatization of the lung parenchyma ( Figure 4b ). Additionally, hyperechoic air bronchograms are often visualized. Pneumonia is often associated with pleural effusion and localized B-lines. Using lung ultrasound, rapid bedside detection of these pulmonary findings in clinical presentations suggestive of pneumonia can accelerate appropriate antibiotic and respiratory supportive treatment.

Left Ventricular Systolic Assessment

Critically ill patients commonly present with a mixed shock picture, and it is rare for a patient to have solely cardiogenic shock, hemorrhagic shock, etc. Rather, a patient who presents in septic shock may have an underlying cardiomyopathy for which she or he is being treated with a beta-blocker.

Cardiomyopathy associated with sepsis is common ¹⁸ and, at least in the case of diastolic dysfunction, it is underdiagnosed and associated with a higher mortality rate. ¹⁹ It is therefore essential that the EP evaluate left ventricular (LV) systolic function rapidly and reliably—particularly in critically ill patients whose disease process may be undifferentiated and whose hemodynamic status is unclear. ^20-22 Bedside echocardiography by the EP is invaluable in identifying the LV contribution to the hemodynamic profile and tailoring resuscitation to optimize patient outcomes.

Although gross visual assessment is the most widely used method by which EPs estimate LV systolic function, this strategy is subjective, operator-dependent, and requires at least two quality views to understand the heart’s three-dimensional movement. However, when faced with a rapid diagnostic dilemma, a global visual estimate of the overall contractility (hyperdynamic, normal, depressed, severely depressed) may be more useful than estimating the ejection fraction (EF), especially when the patient’s baseline EF is unknown.

Regional Wall-Motion Abnormalities

Regional wall-motion abnormalities can be evaluated by considering and correlating the coronary artery distributions with the electrocardiographic findings and the clinical scenario ( Figure 5 ).

Figure 5.

Each region can be assessed for degree of movement of the myocardium toward the center of the LV during systole, or abnormal thickening of the ventricular walls. Although the American Heart Association uses a 17-segment model for this assessment, this level of detail may not be necessary for a POCUS evaluation. ²³

Simpson’s Rule

Although no one parameter can quantitatively assess LV function, the EF is the one most commonly used. The Simpson’s Rule or the “method of disks” estimates EF by changes in calculated ventricular volumes. The endocardial border is outlined in end-diastole and end-systole (ES) in both the apical four- (AP4) and two-chamber views. The cardiac package on the ultrasound system can divide the selected area into a series of disks, calculate the volume of each disk, and then add these figures to estimate the ventricular volume ( Figure 6a ). Limitations of this study include potentially difficult visualization of the endocardial border, and the length of time to conduct this study.