Critical Care Ultrasound Training

1. The arrested patient Ad apted from Lichtenstein's SESAME protocol (with permission)

3. 1. Formulate the question

5. Is there a reversible cause? Tension PTX Tamponade Toxins Thrombosis (MI) Thromboembolism (PE) Hypovolaemia Hypothermia Hypoglycaemia Hyperkalaemia Hydrogen (acidosis)

6. Is there a reversible cause? Tension PTX Tamponade Toxins Thrombosis (MI) Thromboembolism (PE) Hypovolaemia Hypothermia Hypoglycaemia Hyperkalaemia Hydrogen (acidosis)

7. Successful intubation? Bilateral pleural sliding = both lungs ventilated Unilateral sliding = 1 lung ventilation / PTX No sliding = maybe the ETT is in the oesophagus / NB bilateral PTX?

8. 2. The arrest screen

9. Curved probe, abdominal preset Sagittal axis Just like FAST!

11. Don ’ t get in the way of CPR You need to scan during the pulse check You have ten seconds! CPR Pulse check & scan lungs CPR Pulse check & scan heart CPR Pulse check & consider options

12. The arrest scan

13. Step 1 Single view of heart

14. What am I looking for? Is there a heartbeat? Pericardial effusion? RV > LV?

16. Subcostal scan heart

17. 1

19. 2

20. Pericardial fluid It ’ s a tamponade Caveat: it might be an incidental finding What if you ’ re wrong? What have you got to lose? Action: pericardiocentesis

21. 3

22. Active heart, small LV = PEA Pseudo-EMD Hypovolaemia Action: replace volume Find & treat cause = go to step 3

23. 4

24. Cardiac standstill Exclude other reversible causes (Hs, Ts) Action: cease CPR

25. Inadequate view Options: Try another window Try cardiac probe Get help

26. Step 1: single view heart Big RV S quashing LV Pericardial fluid Cardiac standstill Inadequate view Small volume heart beating ?

27. Step 1: single view heart Big RV Pericardial fluid Cardiac standstill Inadequate view Pseudo-EMD PE Consider thrombo-lysis Tamponade Drainage Hypovolaemia IV fluid Proceed to step 3 R.I.P. Exclude other reversible causes Cease CPR Keep looking Get help

28. Step 1: single view heart Pseudo-EMD Hypovolaemia IV fluid Proceed to step 2

29. Step 2 Anterior chest

32. Step 2 findings Neither lung is sliding? One lung is not sliding? Both lungs sliding

33. Step 2 findings Neither lung is sliding? One lung is not sliding? Both lungs ventilating PTX or 1 lung ventilation Not ventilating! (NB bilateral PTX?) No PTX Lungs are ventilating

34. Step 2 findings Neither lung is sliding? One lung is not sliding? Both lungs ventilating PTX or 1 lung ventilation Not ventilating! No PTX Check the airway Check the ETT Is there a lung Point (PTO)? Go to step 3

35. Recall: the lung point At the edge of a PTX, you can sometimes see normal lung moving US image: 1 side of image doesn't slide with breathing (= the PTX); the other side shows sliding (= the lung) This spot is the lung point & is 100% specific to PTX

36. What if there's no lung point? Maybe 1 lung ventilation Maybe a massive PTX ( entire lung collapsed)

37. What if there's no lung point? Maybe 1 lung ventilation Maybe a massive PTX ( entire lung collapsed) Be a doctor Go back to clinical picture & urgently drain the PTX or pull back the ETT

39. Recap: the arrest screen

41. Step 1: single view heart Big RV Pericardial fluid Cardiac standstill Inadequate view Pseudo-EMD PE Consider thrombo-lysis Tamponade Drainage Hypovolaemia IV fluid Proceed to step 3 R.I.P. Cease CPR Keep looking Get help

42. Step 2: anterior lungs Neither lung is sliding? One lung is not sliding? Both lungs ventilating PTX or 1 lung ventilation Not ventilating! No PTX Check the airway Check the ETT Is there a lung Point (PTO)? Go to step 2

44. Watch the video again

45. Further tests? when resuscitation phase completed