2/23/2017

1

CASE STUDIES IN ULTRASOUNDSarah Davis, DNP, ACNP-BC, FNP-BC & Jennifer Wilbeck, DNP, ACNP-BC, FNP-BC, ENP-C, FAANP

Objectives

►At the conclusion of this presentation, learners will be able to demonstrate the use of bedside ultrasound for the :— Assessment & management of shock

— Assessment & management of abscess

— Assessment & management of endocarditis

— Procedure of joint injections

— EXTRA: Assessment & management of abdominal, bony & extremity pain

2/23/2017

2

Bedside Ultrasound in Emergency Care

►Enhances diagnosis, resuscitation, monitoring, & treatment of acute conditions at bedside

►Guides procedural techniques

►Incredibly operator dependent

Commonly Used Transducers

https://upload.wikimedia.org/wikipedia/commons/b/b7/UsMachTxPhoto.jpg

2/23/2017

3

Ultrasound 101: Review

►Correct— Transducer

— Marker Positioning

— Depth

— Gain

— Positioning (the provider and the pt)

►Echogenicity

ASSESSMENT OF SHOCK

Insert Photo/Illustration credits here

2/23/2017

4

TYPES OF SHOCK

►Hypovolemic►Obstructive►Cardiogenic►Distributive

—Neurogenic —Anaphylactic—Septic

Inadequate tissue perfusion and cellular hypoxia are present in

every type of shock

Overall Goals of Shock Management

►Provide supportive therapy to affected body systems WHILE finding, managing, and treating the shock source

►IV access, central preferred

2/23/2017

5

Rapid Ultrasound in Shock Protocol (RUSH)

►Used in undifferentiated shock for rapid eval of reversible causes

►Improves accurate diagnosis in undifferentiated hypotension

►Utilizes 3-part bedside assessment— The pump

— The tank

— The pipes

►Always start with heart and IVC/IJ veins, then tailor clinically

Seif, D., Perea, P., Mailhot, T., Riley, D., & Mandavia, D. Bedside Ultrasound in Resuscitation & the Rapid Ultrasound in Shock Protocol (2012). Critical Care Research & Practice

RUSH Protocol Summary

Taken directly from: Seif, D., Perea, P., Mailhot, T., Riley, D., & Mandavia, D. Bedside Ultrasound in Resuscitation & the Rapid Ultrasound in Shock Protocol (2012). Critical Care Research & Practice. Available at https://www.hindawi.com/journals/ccrp/2012/503254/abs/

2/23/2017

6

https://i1.wp.com/emcrit.org/wp-content/uploads/2011/03/RUSH-ED-sequencing-2017-01-30.jpg

HYPOVOLEMIC SHOCK

2/23/2017

7

Hypovolemic Shock

► Loss or redistribution of volume (blood, plasma, or other body fluids) which result in decreased intravascular volume

► Signs and symptoms noticeable when intravascular volume reduced by >15%

► Inadequate preload — Decreased diastolic filling 

— Decreased cardiac output

2/23/2017

8

Hypovolemic Shock Causes

►Acute blood loss or ongoing hemorrhage

►Fluid depletion (Non-hemorrhagic)

►Gastrointestinal (Vomiting/diarrhea)

►Burns

►Polyuria

►Aggressive pharmaceutical diuresis

►Insensible losses

2/23/2017

9

Classes of Hemorrhagic Shock

Assessment: Inferior Vena Cava (IVC) Evaluation

►Vena cava is a collapsible vein— Not affected by vasoconstriction— Changes in size based on intravascular volume

►Evaluated by ECHO— Size (<1.2 cm)— Respiratory variation (>50% collapse with inspiration)

►More accurate indicator of potential volume responsiveness than CVP

2/23/2017

10

2/23/2017

11

Hypovolemic Shock Treatment

►Appropriate/meaningful volume resuscitation— Crystalloid boluses with ongoing infusion— Blood product administration

►CAUTIOUS use of vasopressors— Fill before you squeeze!

►Optimized oxygen delivery

►Treatment of underlying hypovolemic cause

2/23/2017

12

OBSTRUCTIVE SHOCK

Obstructive Shock

►Mechanical obstruction impacting the cardiovascular system that decreases ventricular filling and/or emptying

►End result is decreased cardiac output, decreased tissue perfusion, and oxygen delivery

2/23/2017

13

Obstructive Shock Causes

► Decreased ventricular filling— Cardiac tamponade

— Tension pneumothorax

— Vena cava compression or thrombus

— Atrial mass or thrombus

►Decreased ventricular emptying— Pulmonary embolism

https://upload.wikimedia.org/wikipedia/commons/2/2f/Pneumothorax_CXR.jpg

2/23/2017

14

Pneumothorax

►Free air in the pleural space

►Can be Primary or Secondary— Spontaneous: No evidence of lung dz.— Secondary: Lung disease comorbidity

►Tension PTX must be ruled out!— Decreased in venous return to R heart— Decreased CO— Mediastinal shift

Pneumothorax

2/23/2017

15

Lung sliding or no lung sliding?

2/23/2017

16

Simple Pneumothorax

CXR should be Upright,

end-expiration

Tension Pneumothorax

►Hypotension

►Tachycardia

►Diaphoresis

►Cardiovascular Collapse

►Tracheal Deviation

2/23/2017

17

Management: Needle Thoracostomy

https://65.media.tumblr.com/tumblr_lv49d27nwn1qafl51o1_500.jpg

►Use with unstable patient with Tension PTX

►14-18G angio, 2nd ICS MCL OR 4th-5th ICS, Anterior axillary line

►Need long enough catheter

Hemothorax

►Blood in intrapleural space

►Lung can hold up to 2L blood

►No sxs with small amount— 200 mL to be seen on CXR

►Large HTX (> 1L) = Shocky

2/23/2017

18

Obstructive Shock Management

►Rapid treatment of the cause

►Gentle volume and vasopressor use— Temporizing measure only

►Airway stabilization

https://upload.wikimedia.org/wikipedia/commons/9/9f/Blausen_0164_CardiacTamponade_02.png

CARDIOGENIC SHOCK

Insert Photo/Illustration credits here

2/23/2017

19

Cardiogenic Shock

► Occurs when the heart fails as a pump 

► Decreased contractility leads to decreased stroke volume 

► Leads to decreased cardiac output and blood pressure, resulting in decreased tissue perfusion

Cardiogenic Shock Causes

►Myocardial infarction

►HFrEF exacerbation

— Ischemic 

— Non‐ischemic 

►Dysrhythmias

►Left ventricular outflow tract obstruction

— Hypertrophic obstructive cardiomyopathy

2/23/2017

20

Cardiogenic Shock Treatment

►Myocardial infarction— Restoration of coronary artery perfusion

— Anticoagulation, angioplasty, stent, and/or CABG

►HFrEF— Address underlying cause

— Inotropic support, afterload reduction, diuresis

►Dysrhythmias— Antiarrhythmic drugs, DCCV, and/or defibrillation

2/23/2017

21

DISTRIBUTIVE SHOCK

Sepsis and Septic Shock►Sepsis: Infection + ≥ 2 SIRS criteria

►Severe Sepsis: Sepsis plus at least one sign of hypoperfusion or organ dysfunction that is new and not explained and/or a serum lactate level >4.0 mmol/L

►Septic Shock: Severe sepsis associated with refractory hypotension (BP<90/60) despite adequate fluid resuscitation and/or a serum lactate level >4.0 mmol/L

2/23/2017

22

Photo credit: http://www.traumayellow.com/uploads/2/0/9/5/20955098/4670173_orig.png; for more information, see http://www.qsofa.org/index.php#whatis

Goal Directed: Septic Shock Treatment (Part 1)Within 3 hours of presentation:►Measure lactate level

►Obtain cultures before antibiotics: — Two sets of blood cultures— +/- urine culture

►Administer broad spectrum antibiotics

►Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L

2/23/2017

23

Sub Xiphoid View

2/23/2017

24

Goal Directed: Septic Shock Treatment (Part 2)

Within 6 hours of presentation:

►Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg

►In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion

►Re-measure lactate if initial lactate elevated

Serial Ultrasound in Fluid Management

2/23/2017

25

2 hours later….

Same Patient

2/23/2017

26

Septic Shock: Treatment Updates

►Fluids (Crystalloids; albumin if needed)

►Vasopressors— Norepinephrine, epinephrine, vasopressin

►Inotropes if cardiac dysfunction— Dobutamine

►Corticosteroids— ONLY if unable to meet hemodynamic goals

Concluding Points about Shock…

►Shock states are dynamic— Stay vigilant

►Managing shock is a collaborative effort— Utilize your team

2/23/2017

27

ASSESSMENT OF ABSCESSES

Insert Photo/Illustration credits here

Bedside US for Evaluation of Abscesses (soft-tissues)

►Used when physical exam unclear— Assists with identifying location, size & composition

— Differentiate cellulitis vs. abscess

— Especially useful in highly vascular areas—Doppler color settings can identify arteries

2/23/2017

28

Key Assessments in Abscesses (soft-tissues)

►High-frequency linear array or convex array transducer— Convex for deeper fluid collections

— High-frequency linear in peds for smaller footprint

►Use 2 planes to evaluate shape & depth of fluid collections

►Increase gain to visualize subtle details of water content in subcuttissues

Key Assessments in Abscesses (soft-tissues)

Cellulitis Subcutaneous Abscess

Increased distance between the skin & underlying fascia or bone

Organized collection of pus & debris in sharply demarcated area

Increased echogenicity of subcut tissue w/ hypoechoic bands causing cobblestone appearance

Most commonly, hypoechoic roughly spherical mass

+/- Postereior acoustic enhancement and/ormotion of fluid-filled area with palpation

Campo & Lafferty. Essential Procedures for Emergency, Urgent, & Primary Care settings (2nd edition), 228-9.

2/23/2017

29

MANAGEMENT OF ABSCESSES

Insert Photo/Illustration credits here

Overall Management of Abscess

►http://sonoguide.com/abscess.html

►http://emedicine.medscape.com/article/1379916-overview

►http://lbstack.com/US%20Handouts/Soft%20tissue%20handout.pdf

2/23/2017

30

Peritonsillar Abscesses Management

https://upload.wikimedia.org/wikipedia/commons/3/39/PeritonsilarAbsess.jpg

►Airway, pain management, antibiotics— Augmentin or Clinda

►+/- steroids

►Drainage of fluid collection— I&D

— Needle drainage

Ludwig’s Angina

►AIRWAY, vascular access, & broad spectrum antibiotics

►Ultrasound may detect:— Gas in tissues, abscesses & LAD

— Locate airway among edematous anterior neck tissue

— Guide fluid aspirations

2/23/2017

31

ASSESSMENT OF ENDOCARDITIS

Insert Photo/Illustration credits here

Endocarditis must be considered in patients presenting with fever and

stroke-like symptoms

2/23/2017

32

MANAGEMENT OF ENDOCARDITIS

Insert Photo/Illustration credits here

Endocarditis Management

►Ultrasound is an additional tool to assess if there is an effusion in the setting of pericarditis

►Antibiotic therapy— Native vs. prosthetic valves

— Also consider IVDA or congenital anomaly

— Multi-drug therapies

►Surgical intervention may be required

2/23/2017

33

JOINT INJECTIONS

Insert Photo/Illustration credits here

2/23/2017

34

Indications for Joint injections

►Arthrocentesis— Diagnostic— Therapeutic

►Therapeutic Joint injections

►US guidance shown to improve intra-articular needle position, improving outcomes

https://stemcelldoc.files.wordpress.com/2011/11/ultrasound-guided-injection.jpg

EXTRA CASES…

Insert Photo/Illustration credits here

2/23/2017

35

ABDOMINAL PAIN

Insert Photo/Illustration credits here

Pleural Effusions

2/23/2017

36

BONY PAIN

Insert Photo/Illustration credits here

Conclusion

►Ultrasound gaining increased utility in the ED/urgent care settings

►Utility for assessment, management & monitoring of patients

►Highly user-dependent — Practice

— Certification opportunities