2015-01-31 1 Why is my patient crashing? Point-of-care ultrasound for clinical problem solving Jordan Chenkin Objectives • Review POCUS algorithm for undifferentiated shock • Apply algorithm to problem solve difficult emergency cases • Convince you that you need to start doing this Undifferentiated Shock RUSH Exam for Undifferentiated Shock • Heart • IVC • Morison’s • Aorta • Pneumo H - Heart LV contractility Pericardial effusion RV strain I - IVC
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clinical problem solving Undifferentiated Shock RUSH Exam ... · 2015-01-31 6 Embolism In Transit Why was patient getting worse? Bottom Line: Patient in Shock? Case 2 • 65M with
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2015-01-31
1
Why is my patient crashing?
Point-of-care ultrasound forclinical problem solving
Jordan Chenkin
Objectives
• Review POCUS algorithm for undifferentiatedshock
• Apply algorithm to problem solve difficultemergency cases
• Convince you that you need to start doing this
Undifferentiated Shock RUSH Exam for Undifferentiated Shock
• Patient intubated• Vascular surgery consult• Taken to CT
2215h: CTA
2215h: CTA 2215h: CTA
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Aortic Dissection
• 3-5 cases per 100,000/yr• Misdiagnosis up to 50%• Mortality 1% per hour (type A)
• However 80% survival if early dx/tx • Sensitivity 54% (39-68%)• Specificity 94% (90-97%)• Sensitivity 100% for pts in shock
Intern Emerg Med (2014) 9:665–670
Direct Sign: Intimal Flap Direct Sign – Flap (Arch)
Direct Sign – Flap (Carotid) Direct Sign: Flap (abdomen)
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Indirect Sign: AI Indirect Sign: Aneurysm
Case Continued
• 3h delay to OR• Patient arrested on induction• Pronounced 6h after arrival
Case 3
• 82 M brought into resus• Increasing SOB x 3-4 days• Now severe SOB• Increasing leg edema, orthopnea• PMH: CHF (Grade 3 LV), HTN, COPD• Meds: furosemide 40mg, fosinopril,
pravastatin, salbutamol
Case 3
• T 36.0 HR 110 RR 32 BP 173/109 96% NRB• Severe respiratory distress• Crackles and wheezes bilaterally• Pitting edema to thighs bilaterally• JVP elevated