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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?
2、,急诊超声应用范畴,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, abscesses, LPs,可能的诊断,RUSH Exam,This technology is ideal in the care of the critical patient in shock, and the most recent ACEP g
3、uidelines 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 1Evaluation of the Pump,Effusion around the pump: evaluation of the pericardium Squeeze of the pump: determination of global left ventricular function Strain of
4、 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 effusion,Cardiac tamponade
5、,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,Lateral wall,An easy system o
6、f 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 the previous 2 cate
7、gories.,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 for the presence
8、 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 apical 4-chamber
9、view.,Right Ventricle Strain,Thrombus in RA,Differential Diagnosis,Massive PE Smaller and recurrent pulmonary emboli Cor pulmonale Primary pulmonary artery hypertensionAcute right heart strain thus differs from chronic right heart strain in that although both conditions cause dilation of the chamber
10、, 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 pleural flui
11、d 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
12、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
13、 the 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
14、, 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 a complicating parapneumonic pleural effusion, and ascites may lead to spontaneous bacte
15、rial peritonitis.,Right upper quatrant,Left upper quadrant,Pelvic free fluid,Tank compromise: pneumothorax,pneumothorax,Tank overload: pulmonary edema,To assess for pulmonary edema with ultrasound, the lungs are scanned with the phased-array transducer in the anterolateral chest between the second a
16、nd fifth rib interspaces. The presence of B lines coupled with decreased cardiac contractility and a plethoric IVC on focused sonographic evaluation should prompt the clinician to consider the presence of pulmonary edema and initiate appropriate treatment.,B-lines,Step 3Evaluation of the Pipes,Rupture of the pipes: aortic aneurysm and dissection Clogging of the pipes: venous thromboembolism,AAA,A measurement of greater than 3 cm is abnormal and defines an abdominal aortic aneurysm,
