Transcript Case presentation - Middle East Critical Care Assembly

Case presentation & literature review
Two cases
Dr. Saad Subahi
 Consultant cardiologist at ALRIBAT
university hospital
 46 old male admitted electively to hospital
on 12/05/2010 for lamincectomy
 MRI showed disc
prolapse at L4&5
 No significant P.H
 Next morning (13/05/2010) he had
inter laminar discetomy, done under G.A.
 Uneventful course
 2nd 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
 Immediately after mobilization patient
developed sudden SOB; taken back to bed,
noticed to be sweaty with cold extremities .
 Soon, prior to any intervention, respiratory
and subsequently, cardiac arrest ensued
 Advanced cardiac life support was
immediately implemented.
 After resumption of spontaneous circulation
he was transferred to ICU
 Before connecting him to M.V. he had
second arrest; CPR (for 3 minutes) ----->
Resumption of spontaneous
circulation
 Given 2 liters of N/S because of B.P of 75/45,
followed by dopamine infusion, titrated up
to 20mcg/kg/min
 He was connected to M.V. at 11:0 a.m
 I attended the patient at 11.30 am
 Vital signs : pulse 145/min; B.P : 88/52;
oxygen sat 99%
 There was prominent jugular venous
distention.
 The lungs were clear on auscultation, with
normal breath sounds
 12-lead ECG showed sinus tachycardia,
“S 1Q 3T 3” pattern & RBBB
 Chest x-ray : normal
 CBC, Urea & electrolytes were normal
 A presumptive diagnosis of massive
pulmonary embolism was made .
 At 12:15 p.m seen by Dr. Saad & bed side
ECHO done
Dr Saad
 ECHO
 Daignosis
 Discussed with the neurosurgeon and started on streptokinase
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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
 Diagnosis:
Massive PE-induced cardiac arrest
+ right heart thrombi-in-transit
 At 1:30 pm was hemodynamically stable .
 ECHO, next morning (15th) , at 8:15 am
At 10:0 am :
 Improvement in BP & O2 saturation, & he
was obeying commands
 Shifted to spontaneous mode : TV > 300ml,
rate 25-28/min & oxygen saturation 100% on
FIO2 0.40
 Accordingly he was extubated and
connected to oxygen by simple mask (50%)
ABG 30 min post extubation :
 PH
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: 7.35
PCO2 : 37 mmHg
PO2 : 163 mmHg
O2 sat : 99%
HCO3 : 22 mmol/L
BE
: -3 mmol/L
 Time from clinical suspicion to
thrombolytic therapy : one hour
 33 years female presented to the emergency
room with 2 hours history of sudden
shortness of breath
 3/08/2011 at 10.0 am
 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 .
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
 ECG : sinus tachycaria , inverted T- in V1-3
 ABG (NRM) :
PH
: 7.29
PCO2 : 31 mmHg
PO2 : 66 mmHg
HC03 : 16 mmol/l
 Chest x-ray : normal
 High clinical suspicion of massive PE .
 ECHO : done by Dr Saad, within 15 min
from time of presentation .
 1 liter of N/S, followed by dopamine infusion
 ECHO.
 Started immediately on IV streptokinase
1.5 million units over one hour .
 ARRESTED : CPR was carried and
streptokinase infusion was continued
during CPR
 She was intubated and CPR continued for
12 min ------ > ROSC
 Transferred to ICU on dopamine infusion
 Connected to the ventilator
 Improvement of oxygenation, but continued
to require inotropics
 On the same day she had 2nd arrest at
9:30 pm .
 CPR for five minutes ------> ROSC
Hospital course
 AKI required peritoneal dialysis
 Acute peritonitis
 Recovered with a polyuric phase, during
which she developed massive hematuria .
 On day 5 : massive upper GIT bleeding
required blood transfusion.
 On day 7 : blocked ETT .
 Day 11 on mechanical ventilation, she
satisfied all extubation criteria .
 She was extubated and connected to oxygen
by simple mask .
 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 .
 Time from clinical suspicion to
thrombolytic therapy : 20 min.
 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 .
 POLICY STATEMENT
 Emergency Ultrasound Guidelines
 Approved October 2008
 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.
 Bedside Applications of Ultrasound
 Cleveland Clinic February 2013
Introduction
 It was unimaginable 100 years ago to be able
to draw a picture from sound.
 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.”
 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.
 Early ultrasonography
machines were bulky
and their use was
confined to imaging
laboratories.
 Compact and
portable
ultrasound
machines that
provide excellent
image quality
 Has resulted in
profusion of
bedside
applications
 The concept of an
ultrasound
stethoscope is
becoming a
reality.
 Ultrasonography has been widely used in
cardiology, radiology, obstetrics, and
emergency medicine.
 More recently, its use has become more
widespread in pulmonary and critical
care medicine.
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.
 Has 2 primary uses in pulmonary
and critical care medicine:
 Procedural guidance
 Rapid bedside diagnosis in critically ill
patients
Ultrasound-guided procedures
 Some of the common ultrasound-guided
procedures performed in the critical care
unit include
Establishing vascular access and
monitoring catheters
Pericardiocentesis
Thoracentesis and pleural catheter
placement
Paracentesis
Lumbar punctures
Arthrocentesis
Regional
anesthesia
Ultrasound guided crycothyrotomy
and tracheostomy
Confirmation of transvenous
pacing wire placement
Diagnostic applications of Point-ofcare 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.
 Interpretation of the ultrasound images and
immediate clinical decisions are made by
the clinician conducting the imaging study,
thereby enabling rapid intervention and
assessment.
 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.
Advantages point-of-care
ultrasound
 Fast
 Performed at the bedside
 Non-invasive
 Immediate results
 Repeatable
 Nonexpensive
 without the risk of radiation
Point-of-care ultrasound
 Goal-Directed Echocardiography
 Lung Ultrasonography
 Goal-Directed Abdominal
Ultrasonography
 Goal-Directed Vascular Ultrasonography
Lung Ultrasonography
 International evidence-based
recommendations for point-of-care
lung ultrasound.
Intensive Care Med (2012) 38:577–591
Pleural effusion
Pneumothorax
Lung consolidation
Interstitial syndrome
 Pulmonary edema of various causes
 Interstitial pneumonia or pneumonitis
 Diffuse parenchymal lung disease
(pulmonary fibrosis)
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.
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.
 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
 Transthoracic Echo, performed at the
patient’s bedside and interpreted by the
treating intensivist to answer specific
clinical questions.
 The principal role for FOCUS is the
time-sensitive assessment of the
symptomatic patient.
Clinical Indications for Focused Echo
 Hypotension/Shock
 Dyspnea/Shortness of Breath
 Chest pain
 Cardiac Trauma
 Cardiac Arrest
Goals of the Focused echo in the
Emergent Setting
 Assessment of global cardiac systolic
function and contractility
 Assessment of the right ventricular
function
 Assessment for the presence of
pericardial effusion
 Intravascular Volume assessment
 Cardiac arrest
 Volume Assessment
 Chest pain
Cardiac arrest
 Successful resuscitation requires
potentially reversible causes to be
diagnosed and reversed, and many of
these can readily be diagnosed using
echocardiography.
 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.
 Focused echocardiography can be
performed within the time frame allowed
during the pulse check of the advanced life
support (ALS) algorithm.
 A sub-xiphoid
probe position has
been recommended.
 The goal of the FOCUS in the setting of
cardiac arrest is to improve the outcome of
cardiopulmonary resuscitation by:
 Determining a cardiac etiology of the
cardiac arrest :
 Tamponade
 Coronary artery disease
 Pulmonary embolism
 hypovolemia
 Identifying organized cardiac
contractility to help the clinician
distinguish between:
-Asystole
-Pulseless electrical activity (PEA) and
-Pseudo-pulseless electrical activity,
 True PEA is defined as the clinical absence
of ventricular contraction despite the
presence of electrical activity.
 Whereas pseudo-PEA is defined as the
presence of ventricular contractility
visualized on cardiac ultrasound in a patient
without palpable pulses.
 Therefore, making the diagnosis of pseudo-
PEA can be of diagnostic and prognostic
importance.
 If mechanical contractility without palpable
pulse is identified (pseudo-PEA), the
management can then focus on
hypotension rather than asystolic type
resuscitation pathways.
Lastly
 Guiding life-saving procedures at the
bedside such as pericardiocentesis, or
evaluate the position of transvenous
pacemaker placement.
Volume Assessment
 In the critically ill, a number of parameters
have been found to indicate severe
hypovolaemia.
 These include :
 The presence of a small, hyperkinetic left
ventricle (in the presence of a normal right
ventricle) with end-systolic cavity
obliteration.
 A left ventricular end-diastolic area of less
than 5.5 cm2/m2 body surface area.
 A small inferior vena cava (diameter <1 cm)
with inspiratory collapse, in spontaneously
breathing patients.
Chest Pain
 The life-threatening chest pain
syndromes where FOCUS may be helpful
are in the evaluation of patients with :
 Hemodynamically significant
pulmonary embolus
 In screening patients with suspected
aortic dissection
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.
 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
 Echocardiography using the
transthoracic approach is of great value
in the critical care setting because of its
portability, widespread availability, and
rapid diagnostic capability.
 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.
 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.
 Focused training with the transthoracic
approach should be offered to all
intensivists.
 This is an essential facet of critical care
education that we can and should help
spearhead.
 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-ofcare ultrasound following a set of
symptom based scanning protocols.
 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.
 Should a hand-carried ultrasound
machine (visual stethoscope) become
standard equipment for every
intensivist ?
Thank
You!
 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
 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
 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.