急診超聲對(duì)于休克患者的鑒別診斷(劉繼海)

急診科醫(yī)生主導(dǎo)的床旁超聲技術(shù)在急診臨床中的應(yīng)用北京協(xié)和醫(yī)院急診科劉繼海2015-4主要內(nèi)容急診超聲和普通超聲的區(qū)別？以不明原因休克患者RUSH檢查為例進(jìn)一步闡釋急診超聲的重要性急診超聲的未來(lái)發(fā)展方向？急診超聲技術(shù)的開展帶來(lái)的沖擊“爭(zhēng)地盤”或“搶飯碗”——該不該做？“資質(zhì)問題”與“收費(fèi)問題”——如何做？“難做嗎”與“做得準(zhǔn)嗎”——培訓(xùn)與質(zhì)量控制如何解決？急診超聲vs.普通超聲急診醫(yī)生床旁超聲檢查旨在最短的時(shí)間內(nèi)得到明確的診斷線索（帶著問題進(jìn)行超聲檢查）:患者各漿膜腔有液體嗎?患者有腹主動(dòng)脈瘤嗎?患者有宮內(nèi)妊娠嗎?患者有深靜脈血栓嗎?患者的心臟在收縮嗎?正常還是異常?急診超聲應(yīng)用范疇表2.1CCEP急診超聲基本應(yīng)用2013創(chuàng)傷超聲重點(diǎn)評(píng)估腹主動(dòng)脈超聲重點(diǎn)評(píng)估心臟急診重點(diǎn)超聲超聲引導(dǎo)操作技術(shù)氣道急診超聲評(píng)估表2.2CCEP急診超聲高級(jí)應(yīng)用2013肺急診重點(diǎn)評(píng)估外周血管急診重點(diǎn)評(píng)估腹部急診重點(diǎn)評(píng)估婦產(chǎn)科急診重點(diǎn)評(píng)估陰囊急診評(píng)估眼睛急診評(píng)估與醫(yī)療質(zhì)量息息相關(guān)危重患者的快速有針對(duì)性的超聲檢查，提高診斷效率:FAST,AAA,CardiacinPEAorhypotension改進(jìn)患者的流程，減少急診滯留時(shí)間:DVT,Pelvicsonoinearlypregnancy幫助我們完成一些操作，降低風(fēng)險(xiǎn):Centrallines,abscesses,LPs急診超聲有別于傳統(tǒng)的超聲檢查傳統(tǒng)的超聲檢查更加注重某個(gè)臟器病變的檢查和描述，急診超聲則從臨床出發(fā)，有目的的對(duì)急診患者進(jìn)行超聲的重點(diǎn)掃查，對(duì)于患者的疾病狀態(tài)和臟器功能狀況做出更為直觀的評(píng)價(jià)，并根據(jù)檢查的結(jié)果對(duì)患者進(jìn)一步治療和處置提出指導(dǎo)意見。

——由急診醫(yī)師主導(dǎo)的超聲檢查技術(shù)，被譽(yù)為“急診醫(yī)師的可視聽診器”——評(píng)估危重癥患者病情、對(duì)于危及生命的急診疾病做出快速的診斷提高了急診患者的診治效率

——引導(dǎo)臨床侵入性操作及指導(dǎo)相關(guān)急診狀況的處置等，有效降低了侵入性操作并發(fā)癥的發(fā)生率病例24歲女性，58公斤，既往健康，僅口服避孕藥。因“暈倒”被急救車送入院。病人意識(shí)模糊，病史有限。GCS（格拉斯哥昏迷評(píng)分）5-6，BP73/42，脈搏80次/分，體溫38.3℃，SpO292%（在吸氧4升/分鐘的情況下），呼吸26次/分，大汗，右小腿及腳部明顯腫脹。胸片無(wú)明顯異常。心電圖——竇性心律，血糖4.3mM/L?？赡艿脑\斷LeftventricularfailureTensionpneumothoraxHemoperitoneumAnaphylaxisSeveredehydrationNeurogenicshockCardiactamponadeValvulardysfunctionPulmonaryembolusOccultmedicationerrororoverdoseSepsisRupturedaneurysmAorticdissectionMyocardialischemia/infarctionThyrotoxicosisAdrenalfailureDysrhythmiaAutonomicdysfunctionOccultgastrointestinalbleedMesentericischemiaAbdominalinflammation

RUSH

ExamThistechnologyisidealinthecareofthecriticalpatient

inshock,andthemostrecentACEPguidelinesfurtherdelineateanewcategoryof

‘‘resuscitative’’ultrasound.Step1:Thepump（泵）Step2:Thetank（血容量）Step3:Thepipes（血管）

Step1—EvaluationofthePump‘‘Effusionaroundthepump’’:evaluationofthepericardium‘‘Squeezeofthepump’’:determinationofgloballeftventricularfunction‘‘Strainofthepump’’:assessmentofrightventricularstrainEvaluationofthePumpNormalsubxiphoidNormalparasternallongNormalparasternalshortLateralwallNormalparasternalshort

atlevelofaorticvalveNormalapical4LateralwallNormalapical2AnteriorwallPericardial

effusionCardiactamponade‘‘Squeezeofthepump’’determinationof‘‘howstrongthepumpis?”avisualcalculationofthepercentagechangefromdiastoletosystoleMotionofanteriorleafletofthemitralvalvecanalsobeusedtoassesscontractility.NormalparasternallongNormalparasternalshortLateralwallAneasysystemofgradingTojudgethestrengthofcontractionsasgood,withthewallsoftheventriclecontractingwellduringsystole;Poor,withtheendocardialwallschanginglittleinpositionfromdiastoletosystole;Intermediate,withthewallsmovingwithapercentagechangeinbetweentheprevious2categories.BenefitsKnowingthestrengthofleftventricularcontractilitywillgivetheEPabetterideaofhowmuchfluid‘‘thepump’’orheartofthepatientcanhandle,beforemanifestingsignsandsymptomsoffluidoverload.Incardiacarrest,theclinicianshouldspecificallyexamineforthepresenceorabsenceofcardiaccontractions.‘‘Strainofthepump’’Onbedsideechocardiography,thenormalratioofthelefttorightventricleis1:0.6.Theoptimalcardiacviewsfordeterminingthisratioofsizebetweenthe2ventriclesaretheparasternallongandshort-axisviewsandtheapical4-chamberview.RightVentricleStrainThrombusinRADifferentialDiagnosisMassivePESmallerandrecurrentpulmonaryemboliCorpulmonalePrimarypulmonaryarteryhypertensionAcuterightheartstrainthusdiffersfromchronicrightheartstraininthatalthoughbothconditionscausedilationofthechamber,theventriclewillnothavethetimetohypertrophyifthetimecourseissudden.‘‘Evaluationofthepipes”Step2:EvaluationoftheTank‘‘Fullnessofthetank’’:evaluationoftheinferiorcavaandjugularveinsforsizeandcollapsewithinspiration‘‘Leakinessofthetank’’:FASTexamandpleuralfluidassessment‘‘Tankcompromise’’:pneumothorax‘‘Tankoverload’’:pulmonaryedemaEvaluationoftheTank‘‘Fullnessofthetank’’M-mode

DopplerHow

to

determine？AsmallercaliberIVC(<2cmdiameter)withaninspiratorycollapsegreaterthan50%roughlycorrelatestoaCVPoflessthan10cmofwater.This

phenomenonmaybeobservedinhypovolemicanddistributiveshockstates.Alarger

sizedIVC(>2cmdiameter)thatcollapseslessthan50%withinspirationcorrelatesto

aCVPofmorethan10cmofwater。Thisphenomenonmaybeseenin

cardiogenicandobstructiveshockstates.High

cardiac

filling

pressureTwocaveatstothisruleexistThefirstis

inpatientswhohavereceivedtreatmentwithvasodilatorsand/ordiureticspriorto

ultrasoundeval