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Ultrasound in ICU and Emergency
1. Ultrasound in ICU
and Emergency
Gamal Agmy, MD, FCCP
Professor of chest Diseases, Assiut university, Assiut, Egypt
2.
3. Bedside Chest Radiography in the
Critically ill Patients
At the bedside, chest radiography remains the
reference for lung imaging in critically ill patients.
However, radiographical images are often of limited
quality
12. A lines = default normal
Horizontal echo
reflection at exact
multiples of intervals
from surface to
bright reflector.
Dry lung OR PNTX
Decay with depth
Obliterated by B
pleura A
A
A
A
A
A
21. • Absent lung sliding
• Exaggerated horizontal artifacts
• Loss of comet-tail artifacts
• Broadening of the pleural line to a band
• Lung point
• Loss of lung impulse
The key sonographic signs of
Pneumothorax
22.
23.
24.
25.
26.
27.
28.
29. Confluent B lines = Bad Bad
‘White’ or ‘shining’
lung
Means increased
severity
Probably indicates
thicker fluid in alveoli
eg protein or
inflammatory cells
% space / 10
30.
31. B x 3 x 2 x 2 = CCF
Makes assumption that ‘globally’ wet
lungs are most likely to be CCF
12
40. Schematic representation of the parenchymal, pleural and vascular
features associated with pulmonary embolism.(Angelika Reissig, Claus
Kroegel. Respiration 2003;70:441-452)
41.
42. PE DIAGNOSTIC ACCURACY
LUS for diagnosis of PE
Metaanalysis:
- Sens.: 80% (75-83%)
- Spec.: 93% (89-96%)
Niemann T et al. Transthoracic sonography for the detection of pulmonary embolism–a meta-analysis.
Ultraschall Med 2009 30:150–156
45. Tissue pattern representative of Alveolar
Consolidation
Presence of hyperechoic punctiform
imagesrepresentative of air bronchograms
Pleural
effusion
Lower lobe
46. FLUS: IS PRESENT? YES/NO
Normal pattern IS pattern
Cardiogenic pulm. edema:
Excluded – COPD exa?
Cardiogenic pulm. edema:
Suspected
47.
48.
49. BLUE-Protocol and FALLS-Protocol
Two Applications of Lung Ultrasound
in the Critically Ill
(Daniel A. Lichtenstein , MD , FCCP, CHEST
2015; 147 ( 6 ): 1659 - 1670
56. Where to put the probe…
Supine position
Subxiphoid
Orientate probe in
longitudinal plane with
probe indicator to
patient’s head
Slightly to right of
midline
68. Parasternal long axis
Transducer at left sternal
edge between 2nd -4th
intercostal space
Probe marker pointing to
patients R shoulder
Probe aligned along the
long axis: from R shoulder
to cardiac apex.
Useful view to assess
contractility
69. Apical 4 chamber
Transducer at 4th-6th intercostal
space in the midclavicular to
anterior-axillary line.
Probe directed towards patient’s
right shoulder with the marker
directed towards the left
shoulder.
Important view to give relative
dimensions of L and R ventricle.
Normal ventricular diameter
ratio of R ventricle to L ventricle
is <0.7.
70.
71. PericardialTamponade
Remember tamponade is a clinical diagnosis based on
patient’s haemodynamics and clinical picture.
Ultrasound may demonstrate early warning signs of
tamponade before the patient becomes haemodynamically
unstable.
Haemodynamic effects
Its PRESSURE NOT SIZE THAT COUNTS!
Rate of formation affects pressure-volume relationship and
is therefore more important than volume of fluid.
72. Tamponade using ultrasound
A moderate-large effusion.
Right atrial collapse
Atrial contraction normal in atrial systole
Collapse throughout diastole or inversion is abnormal.
RV collapse during diastole when meant to be filling
(‘scalloping’ seen)