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A bedside clinical and ultrasound-based approach to hemodynamic instability - Part II: bedside ultrasound in hemodynamic shock: Continuing Professional Development

Approches cliniques et échographiques au chevet du patient pour la gestion de l’instabilité hémodynamique - 2e partie: l’échographie au chevet en cas de choc hémodynamique

Abstract

Shock is defined as a situation where oxygen transport and delivery is inadequate to meet oxygen demand. The patient in shock is evaluated through medical history, physical examination, and careful observation of the hemodynamic and respiratory monitors. The patient is initially managed with basic resuscitation measures, however bedside ultrasound should be performed if hemodynamic instability persists. We propose to use ultrasound of the inferior vena cava (IVC), and the concept of venous return, as the initial step in order to identify the mechanism of shock. Doppler examination of the hepatic venous flow can also be added. Further ultrasound examination of the patient’s heart, thorax, and abdomen can then be performed in order to determine the etiology of shock. In patients with reduced mean systemic venous pressure, an examination of the patient’s thoracic and abdominal cavities to detect free fluid, pneumonia, or empyema can be considered. In patients with increased right atrial pressure, transthoracic echocardiography will allow identification of left or right ventricular dysfunction. Finally, in the presence of increased resistance to venous return, thoracic examination for pneumothorax or cardiac tamponade and abdominal examination for signs of abdominal compartment syndrome or IVC occlusion can be considered. Subsequent treatment can then be tailored to the etiology of shock. Elements of bedside ultrasound examination are currently taught in many anesthesia training programs.

Purpose

To develop an approach to the patient in shock that incorporates bedside ultrasound examination.

Résumé

On définit le choc comme une situation dans laquelle le transport d’oxygène est incapable de répondre à la demande en oxygène. On évalue le patient en état de choc en fonction de ses antécédents médicaux, de l’examen physique, ainsi que de l’observation minutieuse des moniteurs hémodynamiques et respiratoires. Le patient est d’abord pris en charge à l’aide de mesures de réanimation de base; toutefois, si l’instabilité hémodynamique persiste, il convient de réaliser une échographie au chevet. Nous proposons d’utiliser une échographie de la veine cave inférieure (VCI) dans le cadre du concept du retour veineux, comme première étape dans l’identification du mécanisme du choc. L’examen Doppler des veines hépatiques peut également être ajouté. Un examen échographique plus approfondi du cœur, du thorax et de l’abdomen du patient peut être réalisé par la suite afin de déterminer l’étiologie du choc. Chez les patients dont la pression veineuse systémique est réduite, on peut envisager un examen des cavités thoracique et abdominale afin de détecter du liquide libre, une pneumonie ou un empyème. Chez les patients dont la pression auriculaire droite est accrue, une échocardiographie transthoracique permettra d’identifier le mécanisme du dysfonctionnement ventriculaire gauche ou droit. Enfin, si le retour veineux rencontre une résistance accrue, on peut envisager de réaliser un examen thoracique afin d’exclure la présence de pneumothorax ou de tamponnade cardiaque et un examen abdominal pour détecter les signes d’un syndrome du compartiment abdominal ou d’une occlusion de la VCI. Le traitement subséquent peut alors être personnalisé en fonction de l’étiologie du choc. Des éléments de l’examen échographique au chevet sont actuellement enseignés dans de nombreux programmes de formation en anesthésiologie.

Objectif

Mettre au point une approche du patient en état de choc qui incorpore l’examen échographique au chevet.

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    Acknowledgements

    The authors sincerely thank Denis Babin and Antoinette Paolitto for their assistance in bringing this manuscript to fruition.

    Funding sources

    Montreal Heart Institute Foundation.

    Conflicts of interest

    None declared.

    Sources de financement

    Fondation de l’Institut de cardiologie de Montréal.

    Conflit d’intérêt

    Aucun.

    Author information

    Correspondence to André Denault MD, PhD.

    Additional information

    This Continuing Professional Development module is the second in a two-part series on the management of patients with hemodynamic instability. In this module, the emphasis is placed on the use of ultrasound to manage patients in shock. The first module, published in September 2014 (Can J Anesth 2014; DOI:10.1007/s12630-014-0203-0), focused mainly on the clinical approach.

    Ce module de Développement professionnel continu est le second d’une série en deux parties portant sur la prise en charge des patients instables hémodynamiquement. Dans ce module, l’emphase est mise sur l’utilisation de l’échographie pour prendre en charge les patients en état de choc. Le premier module, publié en septembre (Can J Anesth 2014; DOI:10.1007/s12630-014-0203-0), traitait principalement de l’approche clinique.

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    Vegas, A., Denault, A. & Royse, C. A bedside clinical and ultrasound-based approach to hemodynamic instability - Part II: bedside ultrasound in hemodynamic shock: Continuing Professional Development. Can J Anesth/J Can Anesth 61, 1008–1027 (2014) doi:10.1007/s12630-014-0231-9

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    Keywords

    • Right Ventricular
    • Inferior Vena Cava
    • Continue Professional Development
    • Right Ventricular Outflow Tract
    • Right Ventricular Failure