心血管急症之應用

陳國智醫師 新光醫院急診醫學科 輔仁大學醫學系 中華民國醫用超音波學會指導醫師
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ACEP 2008 EUS guidelines

Ann Emerg Med. 2009;53:550-570

急救時超音波的角色為何 ?

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休克評估時超音波的角色為何 ?

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超音波下的變化有何不同 ?
• • • • Hypovolemic shock Cardiogenic shock Obstructive shock Distributive shock

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Goal of focused cardiac US in ED
• Assessment for the presence of pericardial effusion • Assessment of global cardiac systolic function • Identification of marked right ventricular and left ventricular enlargement • Intravascular volume assessment • Guidance of pericardiocentesis • Confirmation of transvenous pacing wire placement
J Am Soc Echocardiogr 2010;23:1225-30
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Must-See for EPs
Bedside echocardiography: common views

Breitkreutz, Y et al. Crit Care Med 2007;35:S235-S249

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CAUSE
• Cardiac Arrest Ultra-Sound Examination
– For non-arrhythmogenic cardiac arrest – No or minimal interruption of CPR

2012/1/9 2012/1/9

Resuscitation 2007

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CAUSE for Cardiac Arrest
• • • • Severe hypovolemia Tension pneumothorax Cardiac tamponade Massive pulmonary embolism

2012/1/9 2012/1/9

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Apical Four Chamber View

2012/1/9 2012/1/9

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Pneumothorax

2012/1/9 2012/1/9

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CAUSE for Resuscitation

2012/1/9 2012/1/9

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Focused Echocardiographic Evaluation in Resuscitation (FEER) Management

2012/1/9 2012/1/9

Breitkreutz, R et al. Crit Care Med 2007;35:S150-S162

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FEER in Ten Steps

2012/1/9 2012/1/9

Breitkreutz, R et al. Crit Care Med 2007;35:S150-S162

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Focused Abdominal Sonography in Trauma

FAST
Focused Assessment with Sonography for Trauma

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(Undifferentiated Hypotensive Patient)

UHP Ultrasound Protocol

1. Free intraperitoneal fluid evaluation 2. Focused cardiac examination 3. Focused abdominal aorta evaluation
Am J Emerg Med 2001

3 Scanning of UHP protocol

Am J Emerg Med 2001

Goal-directed US for nontraumatic hypotension in ED
• 1. Subcostal view – Cardiac tamponade • 2. Inferior vena cava (IVC) view: Collapsibility 50% – Intravascular volume status • 3. Parasternal long cardiac view – LV function and pericardial effusion • 4. Apical four-chamber cardiac view – Ventricular size and LV function • 5. Hepatorenal recess view – Free intraperitoneal fluid • 6. The pelvis and retrovesical view – Free intraperitoneal fluid • 7. Abdominal aorta view – Any diameter >3 cm CCM 2004

SBP <90 Shock index >1 One s/s of shock

Diagnosis accuracy 80% vs 50%

CCM 2004

Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) protocol

EMJ. 2009;26;87-91

ACES protocol

EMJ. 2009;26;87-91

IVC & RAP

EMJ. 2009;26;87-91

EMJ. 2009;26;87-91

in the Evaluation of the Critically Ill (危急重症患者休克時快速超音波評估)

Rapid Ultrasound in SHock

The RUSH Exam

Step 1: The pump (動力 = 心臟) Step 2: The tank (容積 = 血容量) Step 3: The pipes (管路 = 動靜脈)
Emerg Med Clin N Am 28 (2010) 29–56
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RUSH 步驟 1: 評估動力(心臟)
A. 胸骨旁介面
– 長/短軸

B. 劍突下介面 C. 心尖端介面

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RUSH 步驟 1: 評估動力(心臟)
• ‘‘心臟外圍積液’’
– evaluation of the pericardium

• ‘‘心臟收縮狀態’’
– determination of global left ventricular function

• ‘‘心臟受迫狀態’’
– assessment of right ventricular strain

Emerg Med Clin N Am 28 (2010) 29–56

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RUSH 步驟 2: 評估容積 (血容量)
A. 下腔靜脈長軸 B. 外傷超音波/右上介面
– – 含肋膜介面 含肋膜介面

C. 外傷超音波/左上介面 D. 外傷超音波/骨盆介面 E. 氣胸/ 肺水腫

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RUSH 步驟 2: 評估容積 (血容量)
• ‘‘容積量評估’’
– 下腔靜脈/頸靜脈的大小和隨呼 吸之變化

• ‘‘漏出的液體’’
– 外傷超音波加肋膜掃描

• ‘‘容積受壓迫’’
– 氣胸

• ‘‘容積過多’’
– 肺水腫
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Emerg Med Clin N Am 28 (2010) 29–56

RUSH 步驟 3: 評估管路 (動靜脈)
A. B. C. D. E. F. 胸骨上掃描主動脈 胸骨旁主動脈 上腹部主動脈 臍部上主動脈 股部深部靜脈 膕部深部靜脈

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RUSH 步驟 3: 評估管路 (動靜脈)
• ‘‘管路破裂’’
– 主動脈瘤和主動脈剝離

• ‘‘管路阻塞’’
– 深部靜脈栓塞

Emerg Med Clin N Am 28 (2010) 29–56

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Cardiac arrest & Shock

Ann Emerg Med. 2009;53:550-570

謝謝聆聽
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