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Cardiac US

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hypovolaemia and sepsis

THE HYPOTENSIVE PATIENT

Echo really comes into its own in the hypotensive patient. There are several published guidelines on how to systematically analyse the echo to diagnose the cause of hypotension (1,2,3, 4, 5). All these have similar endpoints. The one I like the best is the which discusses the 5 Es of echo (4): Effusion, ejection, equality, exit and entrance. 

THE 5 Es

EFFUSION

Is there a pericardial effusion and is the heart showing signs of tamponade (RA systolic collapse, RV diastolic collapse, plethoric IVC) ?

EJECTION (LV)

1. reduced: acute/chronic dilated cardiomyopathy or acute/ chronic RWMA 

2. hyperdynamic: hypovolaemia, peripheral vasodilation, RV dysfunction

EQUALITY

Is the RV 1:1 or larger than the LV suggesting RV pressure overload: look for other signs of PE

EXIT

Aorta: consider aortic dissection

ENTRANCE (IVC)

small >50% collapse: consider hypovolaemia

dilated <50% collapse: consider tamponade, PE, tension pneumothorax

RUSH

The RUSH exam (5) tries to make sense of the hypotensive patient by looking for causes of decreased cardiac output with US. 

Start with the cardiac views looking for whether it is obstructive (pericardial effusion/PE) or distributive/hypovolaemic shock.

Confirm the type of shock with the IVC.

Then do a quick eFAST exam looking for intraperitoneal bleeding, large pneumothorax or pleural effusion

Lastly at the aorta for AAA/ Dissection

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Echo in Cardiac Arrest

REFERENCES

1. Atkinson P, Bowra J, Milne J, et al. International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest. CJEM. 2017 Nov;19(6):459-470. doi: 10.1017/cem.2016.394. Epub 2016 Dec 21. Erratum in: CJEM. 2017 Jul;19(4):327. PMID: 27998322.

2. McLean AS. Echocardiography in shock management. Crit Care. 2016 Aug 20;20:275. doi: 10.1186/s13054-016-1401-7. PMID: 27543137; PMCID: PMC4992302.

3. Levitov A, Frankel HL, Blaivas M, Kirkpatrick AW, Su E, Evans D, Summerfield DT, Slonim A, Breitkreutz R, Price S, McLaughlin M, Marik PE, Elbarbary M. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II: Cardiac Ultrasonography. Crit Care Med. 2016 Jun;44(6):1206-27. doi: 10.1097/CCM.0000000000001847. PMID: 27182849.

4. Kennedy Hall M, Coffey EC, Herbst M, Liu R, Pare JR, Andrew Taylor R, Thomas S, Moore CL. The "5Es" of emergency physician-performed focused cardiac ultrasound: a protocol for rapid identification of effusion, ejection, equality, exit, and entrance. Acad Emerg Med. 2015 May;22(5):583-93. doi: 10.1111/acem.12652. Epub 2015 Apr 22. PMID: 25903585.

5. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010 Feb;28(1):29-56, vii. doi: 10.1016/j.emc.2009.09.010. PMID: 19945597.