4 types of shock
Hypovolemic (hemorrhage), cardiogenic (accident), distributive (bee sting), obstructive (tamponade)
1) Pump (heart) 2) Tank (IVC, abdomen, pelvis, pulmonary) 3) Pipes (aorta, femoral and popliteal)
Where does the marker go in a cardiac exam? Everything else?
Marker to patient’s left for cardiac. Right for everything else.
Assessing the pump
1) Contractility (ejection fraction) 2) Effusion 3) RV strain. Assess w/parasternal views (long and short), subxiphoid and apical views.
Poor mans way of assessing ejection fraction
Does the mitral valve slap back towards the aortic valve
What does this patient have?
Pericardial effusion, note the fluid going around the heart
Increased LV ejection fraction, increased volume in the right ventricle and a “D-shaped” septum
Acute RV overload due to PE (RV strain). Note that it is easy to mis-identify the RV in these cases because it is so much larger.
Really thick RV wall in a patient with asthma
Poorly controlled asthma can cause pulmonary HTN and increased RV wall thickness
How do confirm that you are in the RV
Noninvasive way to look at a patient’s volume status
IVC collapses when patient breaths in if patient is hypovolemic ( 2cm = high central venous pressure, this is how it will look if someone has a massive PE, tension pneumothorax or pericardial tamponade.
RUQ (Morrison’s pouch looking for fluid between liver and kidney). LUQ (looking for fluid between kidney and spleen. Bladder (look for fluid behind bladder and in culdesac (Pouch of Douglas) in woman). Look at diaphragm (look for loss of mirror image in liver indicating hemothorax and effusion).
This is a mirror image artifact of what
Hemangioma in the liver
What would this look like if the patient had a pneumothorax?
Normally the visceral and parietal pleura slide against each other. If there is no sliding then you see no sliding and you look for the lead point. You can also use M-mode and look for sands on the seashore, if there are straight lines then you know there is no lung sliding and there is a pneumothorax.
How do you tell if someone has pneumonia or CHF?
Look for comet-tails (vertical B lines as opposed to horizontal A lines which are normal). This is because the ultrasound penetrates the fluid better and comes back like multiple foggy headlights in the morning.
How should you measure the aorta when assessing for aortic aneurism?
Wall to wall, include plaques
What does this patient have going on with his aorta?
How do you assess for DVT?
Find the vessel and try to collapse it. If the vein is not compressed by the time the artery is compressed you know the clot inside the vein is holding the walls open.
Where to check for LE DVT
Femoral and popliteal regions
PE, Acidosis, Tension PTX, Cardiac tamponade, Hypovolemia, MI, Drugs
How do differentiate a pleural effusion from a pericardial effusion
Pericardial effusion has “rat tail” that goes between the heart and descending aorta. The pleural effusion goes behind the aorta.
A patient codes during dialysis. Ultrasound shows “carbonated beverage” in the RV. What is causing her condition?
Air embolism can cause acute RV overload because the heart cannot pump air.
A patient presents with chest pain and dyspnea. Left femoral view shows a non-compressible vein, dilated RV and dilated IVC. There is normal pleural sliding and no comet tails. How do you want to treat him?
Thrombolytics for PE and DVT. Note that you do not thrombolyse every PE, you will definitely do it if you see RV strain.
A patient presents with chest pain and dyspnea. The lungs show comet tails in all lobes bilateral. There is decreased ejection fraction and minor pleural effusion/pericardial effusion. Peripheral veins collapse fine and there is a dilated IVC. What do you give this patient?
Vasopressors to increase cardiac contractility, this patient has CHF.
A woman presents with postpartum dyspnea and fatigue. There is travel pericardial effusion around the LV. What is causing her condition?
Post-partum dilated cardiomyopathy
A patient presents with chest pain, diaphoresis and hypotension. U/S shows the atrial septum pulling in and the posterior wall of the LV is not moving. What is causing his condition?
He has an inferior STEMI
A patient presents after a high-speed car accident with hypotension. FAST exam shows fluid in Morisson’s pouch and fluid behind the urinary bladder. Cardiac exam shows no fluid around the heart and no pneumothorax. How do you treat him?
He has intra-abdominal hemorrhage. You need to do a laparotomy to repair injured abdominal structures.
A patient presents with abdominal pain and a history of CHF. ECHO shows decreased ejection fraction and enlarged IVC. Abdominal exam shows a dilated aorta. What do you need to do?
Send them to surgery to repair AAA. Decreased EF and enlarged IVC is likely due to chronic CHF.
A woman presents with abdominal pain, hypotension and a negative -hCG. There is a lot of fluid in the pouch of Douglas. What ovarian pathology could cause this?
Ruptured ovarian cyst
A patient presents with syncope, hypotension and critical aortic stenosis. The left ventricle is markedly dilated, there is a “rat tail” between the heart and the descending aorta and the RV diastolic filling is markedly decreased. The IVC is dilated. How do you treat this patient?
Pericardiocentesis to tx pericardial tamponade.
A patient presents with atrial flutter and hypotension. IVC is dilated and there is fluid going between the aorta and the heart. RV wall does not collapse during diastole. How do you treat this patient?
Pericardiocentesis. Since the RV is not collapsing you might shock him to get him out of atrial flutter to get blood moving properly again.
A 796 pound woman presents with chest pain and dyspnea. U/S shows sands on the seashore when looking at the chest. There is no pericardial effusion. LV ejection fraction is good. RV is markedly dilated. Peripheral veins are not compressible in the left leg. What is causing her condition?
Common cause of abdominal sepsis in patients who have had their appendix out
Where do 2/3 of AAAs rupture
Retroperitoneal space. This means there will be no positive signs for tamponade, pleural effusion etc.
A patient with COPD presents with dyspnea and hypoxia. U/S shows normal LV EF. There is no evidence of pericardial effusion or tamponade. RV is enlarged. ECG shows S1 Q3 T3. What does this patient have?
A patient presents with recent PE, dyspnea and hypotension. LV EF is normal. U/S shows fluid around the heart and dilated IVC. He is on coumadin. What is causing his condition?
Although initiation of coumadin can cause clots and PE, it can also cause blood thinning and pericardial effusion, which tis patient had.
A patient presents with dyspnea and hypoxia. LV EF is poor. IVC is dilated and comet tails are seen in the lungs. What is causing his condition?
CHF with pulmonary effusions
A woman presents with chest pain during dialysis. Parasternal long view of the heart shows decreased ejection fraction and a minimal amount of pericardial effusion. RV size is normal, The anterior wall of the heart is not pulling in as well as the others. Shortly after she goes into coarse V-fib. What is causing her condition?
The proximal LAD supplies the anterior wall of the heart, she is having and MI.