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Case presentation & literature review Two cases.

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Presentation on theme: "Case presentation & literature review Two cases."— Presentation transcript:


2 Case presentation & literature review

3 Two cases

4 Dr. Saad Subahi Consultant cardiologist at ALRIBAT university hospital


6 46 old male admitted electively to hospital on 12/05/2010 for lamincectomy

7 MRI showed disc prolapse at L4&5 No significant P.H

8 Next morning (13/05/2010) he had inter laminar discetomy, done under G.A. Uneventful course

9 2 nd post-operative day, at 10:30 a.m (Friday) he was seen by the neurosurgeon Patient was comfortable, apart from minimal backache Vitals were stable He was advised to mobilize out of bed

10 Immediately after mobilization patient developed sudden SOB; taken back to bed, noticed to be sweaty with cold extremities.

11 Soon, prior to any intervention, respiratory and subsequently, cardiac arrest ensued

12 Advanced cardiac life support was immediately implemented. After resumption of spontaneous circulation he was transferred to ICU

13 Before connecting him to M.V. he had second arrest ; CPR (for 3 minutes) -----> Resumption of spontaneous circulation

14 Given 2 liters of N/S because of B.P of 75/45, followed by dopamine infusion, titrated up to 20mcg/kg/min

15 He was connected to M.V. at 11:0 a.m I attended the patient at 11.30 am

16 Vital signs : pulse 145/min; B.P : 88/52; oxygen sat 99% There was prominent jugular venous distention.


18 The lungs were clear on auscultation, with normal breath sounds

19 12-lead ECG showed sinus tachycardia, “S 1 Q 3 T 3 ” pattern & RBBB Chest x-ray : normal CBC, Urea & electrolytes were normal

20 A presumptive diagnosis of massive pulmonary embolism was made.

21 At 12:15 p.m seen by Dr. Saad & bed side ECHO done

22 Dr Saad ECHO Daignosis Discussed with the neurosurgeon and started on streptokinase 1.5 million units, over one hour. Events during streptokinase infusion. Hypotension & bradycardia Severe biventricular dysfunction -------  adrenaline infusion Improvement in biventricular function, pulse rate & blood pressure D/C of adrenaline infusion Maintenance of normal B.P Recovery of RT ventricular function

23 Diagnosis: Massive PE-induced cardiac arrest + right heart thrombi-in-transit

24 At 1:30 pm was hemodynamically stable.

25 ECHO, next morning (15 th ), at 8:15 am

26 At 10:0 am : Improvement in BP & O2 saturation, & he was obeying commands

27 Shifted to spontaneous mode : TV > 300ml, rate 25-28/min & oxygen saturation 100% on FIO2 0.40

28 Accordingly he was extubated and connected to oxygen by simple mask (50%)

29 ABG 30 min post extubation : PH : 7.35 PCO2 : 37 mmHg PO2 : 163 mmHg O2 sat : 99% HCO3 : 22 mmol/L BE : -3 mmol/L

30 Time from clinical suspicion to thrombolytic therapy : one hour


32 33 years female presented to the emergency room with 2 hours history of sudden shortness of breath 3/08/2011 at 10.0 am

33 One week prior to presentation she had bilateral fracture of the tibial shaft (RTA), treated conservatively at home (long leg casting). Was completely confined to bed.

34 On presentation to A&E Tachypnic : 40/min Pulse : 140/min. B/P : 70/35 Confused & restless Normal 1+11 heart sounds Chest : normal auscultation

35 ECG : sinus tachycaria, inverted T- in V1-3 ABG (NRM) : PH : 7.29 PCO2 : 31 mmHg PO2 : 66 mmHg HC03 : 16 mmol/l

36 Chest x-ray : normal

37 High clinical suspicion of massive PE.

38 ECHO : done by Dr Saad, within 15 min from time of presentation. 1 liter of N/S, followed by dopamine infusion

39 ECHO.

40 Started immediately on IV streptokinase 1.5 million units over one hour.

41 ARRESTED : CPR was carried and streptokinase infusion was continued during CPR She was intubated and CPR continued for 12 min ------ > ROSC

42 Transferred to ICU on dopamine infusion Connected to the ventilator

43 Improvement of oxygenation, but continued to require inotropics

44 On the same day she had 2 nd arrest at 9:30 pm. CPR for five minutes ------> ROSC

45 Hospital course AKI required peritoneal dialysis Acute peritonitis Recovered with a polyuric phase, during which she developed massive hematuria.

46 On day 5 : massive upper GIT bleeding required blood transfusion. On day 7 : blocked ETT.

47 Day 11 on mechanical ventilation, she satisfied all extubation criteria. She was extubated and connected to oxygen by simple mask.

48 After 29 days in ICU she was transferred to the ward, fully conscious and oriented with normal renal function; and discharged home 5 days later.


50 Time from clinical suspicion to thrombolytic therapy : 20 min.

51 Transthoracic ECHO was done at the bedside in critically ill patients Performed by the clinician who has complete knowledge of the patient’s current clinical status Immediately established the diagnosis and directed towards the appropriate intervention.


53 POLICY STATEMENT Emergency Ultrasound Guidelines Approved October 2008

54 Focused Cardiac Ultrasound in the Emergent Setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency Physicians J Am Soc Echocardiogr 2010;23:1225-30.

55 Bedside Applications of Ultrasound Cleveland Clinic February 2013

56 Introduction It was unimaginable 100 years ago to be able to draw a picture from sound.

57 Similarly it was written in “The Times” in 1834: “The medical profession was unlikely ever to start using the stethoscope because its beneficial application requires much time and gives a good bit of trouble.”

58 Ultrasound, which is our future stethoscope, has passed through the same story, as the medical community was initially reluctant to use it for diagnosing life-threatening conditions by nonradiologists.

59 Early ultrasonography machines were bulky and their use was confined to imaging laboratories.

60 Compact and portable ultrasound machines that provide excellent image quality

61 Has resulted in profusion of bedside applications

62 The concept of an ultrasound stethoscope is becoming a reality.

63 Ultrasonography has been widely used in cardiology, radiology, obstetrics, and emergency medicine.

64 More recently, its use has become more widespread in pulmonary and critical care medicine.

65 Bedside Applications in Pulmonary and Critical Care Medicine Ultrasonography conducted at the bedside by a clinician, known as point-of-care ultrasonography, dates back more than twenty years, but has come to prominence in the last 5-7 years and is spreading quickly.

66 Has 2 primary uses in pulmonary and critical care medicine:

67 Procedural guidance Rapid bedside diagnosis in critically ill patients

68 Ultrasound-guided procedures Some of the common ultrasound-guided procedures performed in the critical care unit include

69 Establishing vascular access and monitoring catheters

70 Pericardiocentesis

71 Thoracentesis and pleural catheter placement

72 Paracentesis

73 Lumbar punctures

74 Arthrocentesis

75 Regional anesthesia

76 Ultrasound guided crycothyrotomy and tracheostomy

77 Confirmation of transvenous pacing wire placement

78 Diagnostic applications of Point-of- care ultrasound In contrast, to formal ultrasound; is performed by the clinician who is currently caring for the patient and who has complete knowledge of the patient’s current clinical status.

79 Interpretation of the ultrasound images and immediate clinical decisions are made by the clinician conducting the imaging study, thereby enabling rapid intervention and assessment.

80 The dynamic nature of the techniques and ability to repeat an examination rapidly, as needed without waiting on an imaging specialist to perform the examination and interpret it, allows the individual intensivist to monitor patient progress and effects of therapeutic interventions.

81 Advantages point-of-care ultrasound Fast Performed at the bedside Non-invasive Immediate results Repeatable Nonexpensive without the risk of radiation

82 Point-of-care ultrasound Goal-Directed Echocardiography Lung Ultrasonography Goal-Directed Abdominal Ultrasonography Goal-Directed Vascular Ultrasonography

83 Lung Ultrasonography International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med (2012) 38:577–591

84 Pleural effusion

85 Pneumothorax

86 Lung consolidation

87 Interstitial syndrome Pulmonary edema of various causes Interstitial pneumonia or pneumonitis Diffuse parenchymal lung disease (pulmonary fibrosis)

88 The four chest areas per side considered for complete eightzone lung ultrasound examination. These areas are used to evaluate for the presence of interstitial syndrome.

89 Focused (goal-directed) echo Since its inception over 60 years ago, echocardiography has remained largely the province of the cardiologist, providing a tool to evaluate anatomical and physiological abnormalities of the heart.

90 In recent years, the application of echocardiography has extended to the diagnosis and monitoring of the critically ill patients in the general intensive care unit --------------> Goal-directed Echo

91 Transthoracic Echo, performed at the patient’s bedside and interpreted by the treating intensivist to answer specific clinical questions.

92 The principal role for FOCUS is the time-sensitive assessment of the symptomatic patient.

93 Clinical Indications for Focused Echo Hypotension/Shock Dyspnea/Shortness of Breath Chest pain Cardiac Trauma Cardiac Arrest

94 Goals of the Focused echo in the Emergent Setting Assessment of global cardiac systolic function and contractility

95 Assessment of the right ventricular function

96 Assessment for the presence of pericardial effusion

97 Intravascular Volume assessment

98 Cardiac arrest Volume Assessment Chest pain

99 Cardiac arrest Successful resuscitation requires potentially reversible causes to be diagnosed and reversed, and many of these can readily be diagnosed using echocardiography.

100 Periresuscitation echocardiography provides the only realtime bedside diagnostic tool that can diagnose some of the potentially reversible causes of cardiac arrest and can be regarded as analogous to pulse oximetry or ECG monitoring.

101 Focused echocardiography can be performed within the time frame allowed during the pulse check of the advanced life support (ALS) algorithm.


103 A sub-xiphoid probe position has been recommended.

104 The goal of the FOCUS in the setting of cardiac arrest is to improve the outcome of cardiopulmonary resuscitation by:

105 Determining a cardiac etiology of the cardiac arrest :

106 Tamponade Coronary artery disease Pulmonary embolism hypovolemia

107 Identifying organized cardiac contractility to help the clinician distinguish between: -Asystole -Pulseless electrical activity (PEA) and -Pseudo-pulseless electrical activity,

108 True PEA is defined as the clinical absence of ventricular contraction despite the presence of electrical activity.

109 Whereas pseudo-PEA is defined as the presence of ventricular contractility visualized on cardiac ultrasound in a patient without palpable pulses.

110 Therefore, making the diagnosis of pseudo- PEA can be of diagnostic and prognostic importance.

111 If mechanical contractility without palpable pulse is identified (pseudo-PEA), the management can then focus on hypotension rather than asystolic type resuscitation pathways.

112 Lastly Guiding life-saving procedures at the bedside such as pericardiocentesis, or evaluate the position of transvenous pacemaker placement.

113 Volume Assessment In the critically ill, a number of parameters have been found to indicate severe hypovolaemia. These include :

114 The presence of a small, hyperkinetic left ventricle (in the presence of a normal right ventricle) with end-systolic cavity obliteration.

115 A left ventricular end-diastolic area of less than 5.5 cm2/m2 body surface area.

116 A small inferior vena cava (diameter <1 cm) with inspiratory collapse, in spontaneously breathing patients.

117 Chest Pain The life-threatening chest pain syndromes where FOCUS may be helpful are in the evaluation of patients with :

118 Hemodynamically significant pulmonary embolus

119 In screening patients with suspected aortic dissection

120 Conclusion While intensivist performed bedside ultrasonography in pulmonary critical care medicine is in the early stages of development, the evidence for its potential benefits continues to accumulate.

121 Ultrasound appears to be a safe, non- invasive, and non-ionizing imaging modality that can be taken to the bedside of a hemodynamically unstable patient to facilitate therapy and to evaluate its efficacy

122 Echocardiography using the transthoracic approach is of great value in the critical care setting because of its portability, widespread availability, and rapid diagnostic capability.

123 Many studies have demonstrated the value of focused echocardiography in the assessment of critically ill patients in the intensive care unit and emergency room settings.

124 There is a need for more involvement by intensivists in performing focused echocardiographic studies as this modality has been well shown to improve patient care.

125 Focused training with the transthoracic approach should be offered to all intensivists.

126 This is an essential facet of critical care education that we can and should help spearhead.

127 In fact, a time may be coming when much of the evaluation of a critically ill patient is performed not with a stethoscope and physical examination but rather point-of- care ultrasound following a set of symptom based scanning protocols.

128 The bottom line is that the ability to make echocariographically guided assessments in the middle of the night while treating a critically ill patient is an invaluable addition to the art of the practice.

129 Should a hand-carried ultrasound machine (visual stethoscope) become standard equipment for every intensivist ?

130 Thank You!

131 While over years guidelines listed CPR as a contraindication for thrombolysis, newer guidelines recommend to consider thrombolysis therapy during CPR in patients with proven or suspected pulmonary embolism Eur Heart J 21: 1301–1336 2000

132 The long-established fear of increased bleeding complications with thrombolytic use after prolonged and vigorous CPR efforts has been confidently dispelled. Am J Cardiol 1992;69:724-8. Intensive Care Med 2001;27:1050-7. Resuscitation 2003;57:49-55. ALS guidelines 2005

133 The guidelines by the American College of Cardiology (ACC) and the American Heart Association (AHA) state that thrombolytic therapy during CPR is no longer contraindicated. Circulation 2004;110:588-636.

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