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1、急诊科医生主导的床旁超声技术 在急诊临床中的应用 北京协和医院 急诊科 刘继海 2015 4 主要内容 急诊超声和普通超声的区别 以不明原因休克患者RUSH检查为例进一步 阐释急诊超声的重要性 急诊超声的未来发展方向 急诊超声技术的开展带来的冲击 争地盘 或 抢饭碗 该不该做 资质问题 与 收费问题 如何做 难做吗 与 做得准吗 培训与质量 控制如何解决 急诊超声 vs 普通超声 急诊医生床旁超声检查旨在最短的时间内 得到明确的诊断线索 带着问题进行超声 检查 患者各浆膜腔有液体吗 患者有腹主动脉瘤吗 患者有宫内妊娠吗 患者有深静脉血栓吗 患者的心脏在收缩吗 正常还是异常 急诊超声应用范畴 表
2、2 1 CCEP急诊超声基本应用 2013 创伤超声重点评估 腹主动脉超声重点评估 心脏急诊重点超声 超声引导操作技术 气道急诊超声评估 表2 2 CCEP急诊超声高级应用 2013 肺急诊重点评估 外周血管急诊重点评估 腹部急诊重点评估 妇产科急诊重点评估 阴囊急诊评估 眼睛急诊评估 与医疗质量息息相关 危重患者的快速有针对性的超声检查 提 高诊断效率 FAST AAA Cardiac in PEA or hypotension 改进患者的流程 减少急诊滞留时间 DVT Pelvic sono in early pregnancy 帮助我们完成一些操作 降低风险 Central lines
3、abscesses LPs 急诊超声有别于传统的超声检查 传统的超声检查更加注重某个脏器病变的检查和描述 急 诊超声则从临床出发 有目的的对急诊患者进行超声的重 点扫查 对于患者的疾病状态和脏器功能状况做出更为直 观的评价 并根据检查的结果对患者进一步治疗和处置提 出指导意见 由急诊医师主导的超声检查技术 被誉为 急诊医师 的可视听诊器 评估危重症患者病情 对于危及生命的急诊疾病做出 快速的诊断提高了急诊患者的诊治效率 引导临床侵入性操作及指导相关急诊状况的处置等 有效降低了侵入性操作并发症的发生率 病例 24岁女性 58公斤 既往健康 仅口服避 孕药 因 晕倒 被急救车送入院 病人 意识模糊
4、 病史有限 GCS 格拉斯哥昏迷评分 5 6 BP 73 42 脉搏80次 分 体温38 3 SpO292 在吸氧4升 分钟的情况下 呼吸26次 分 大汗 右小腿及脚部明显肿胀 胸片无 明显异常 心电图 窦性心律 血糖 4 3mM L 可能的诊断 Left ventricular failureTension pneumothorax HemoperitoneumAnaphylaxis Severe dehydrationNeurogenic shock Cardiac tamponadeValvular dysfunction Pulmonary embolusOccult medicati
5、on error or overdose SepsisRuptured aneurysm Aortic dissectionMyocardial ischemia infarction ThyrotoxicosisAdrenal failure DysrhythmiaAutonomic dysfunction Occult gastrointestinal bleedMesenteric ischemia Abdominal inflammation RUSH Exam This technology is ideal in the care of the critical patient i
6、n shock and the most recent ACEP guidelines further delineate a new category of resuscitative ultrasound Step 1 The pump 泵 Step 2 The tank 血容量 Step 3 The pipes 血管 Step 1 Evaluation of the Pump Effusion around the pump evaluation of the pericardium Squeeze of the pump determination of global left ven
7、tricular function Strain of the pump assessment of right ventricular strain Evaluation of the Pump Normal subxiphoid Normal parasternal long Normal parasternal short Lateral wall Normal parasternal short at level of aortic valve Normal apical 4 Lateral wall Normal apical 2 Anterior wall Pericardial
8、effusion Cardiac tamponade Squeeze of the pump determination of how strong the pump is a visual calculation of the percentage change from diastole to systole Motion of anterior leaflet of the mitral valve can also be used to assess contractility Normal parasternal long Normal parasternal short Later
9、al wall An easy system of grading To judge the strength of contractions as good with the walls of the ventricle contracting well during systole Poor with the endocardial walls changing little in position from diastole to systole Intermediate with the walls moving with a percentage change in between
10、the previous 2 categories Benefits Knowing the strength of left ventricular contractility will give the EP a better idea of how much fluid the pump or heart of the patient can handle before manifesting signs and symptoms of fluid overload In cardiac arrest the clinician should specifically examine f
11、or the presence or absence of cardiac contractions Strain of the pump On bedside echocardiography the normal ratio of the left to right ventricle is 1 0 6 The optimal cardiac views for determining this ratio of size between the 2 ventricles are the parasternal long and short axis views and the apica
12、l 4 chamber view Right Ventricle Strain Thrombus in RA Differential Diagnosis Massive PE Smaller and recurrent pulmonary emboli Cor pulmonale Primary pulmonary artery hypertension Acute right heart strain thus differs from chronic right heart strain in that although both conditions cause dilation of
13、 the chamber the ventricle will not have the time to hypertrophy if the time course is sudden Evaluation of the pipes Step 2 Evaluation of the Tank Fullness of the tank evaluation of the inferior cava and jugular veins for size and collapse with inspiration Leakiness of the tank FAST exam and pleura
14、l fluid assessment Tank compromise pneumothorax Tank overload pulmonary edema Evaluation of the Tank Fullness of the tank M mode Doppler How to determine A smaller caliber IVC 2 cm diameter that collapses less than 50 with inspiration correlates to a CVP of more than 10 cm of water This phenomenon m
15、ay be seen in cardiogenic and obstructive shock states High cardiac filling pressure Two caveats to this rule exist The first is in patients who have received treatment with vasodilators and or diuretics prior to ultrasound evaluation in whom the IVC may be smaller than prior to treatment altering t
16、he initial physiological state The second caveat exists in intubated patients receiving positive pressure ventilation in which the respiratory dynamics of the IVC are reversed Leakiness of the tank FAST exam and pleural fluid assessment In traumatic conditions as a result of a hole in the tank leading to hypovolemic shock In nontraumatic conditions accumulation of excess fluid into the abdominal and chest cavities often signifies tank overload In infectious states pneumonia may be accompanied by
