1 / 28

The ACES scan

The ACES scan Ultrasound in hypotension Richard Kendall Paul Atkinson The ACES scan A bdominal (and) C ardiac E valuation (with sonography in) S hock The ACES scan Extension of more established emergency medicine uses of ultrasound Abdominal component Cardiac component

Albert_Lan
Download Presentation

The ACES scan

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. The ACES scan Ultrasound in hypotension Richard Kendall Paul Atkinson emergencyultrasound.org.uk

  2. TheACES scan • Abdominal (and) • Cardiac • Evaluation (with sonography in) • Shock emergencyultrasound.org.uk

  3. The ACES scan • Extension of more established emergency medicine uses of ultrasound • Abdominal component • Cardiac component • (Peripheral component) emergencyultrasound.org.uk

  4. Case 1 • ‘Red call’ • Elderly female – collapsed and absent radial pulse • Arrives – peri-arrest • Groaning • Initial resuscitation • ACES scan emergencyultrasound.org.uk

  5. Case 1 • Huge AAA, tender • Terminal care instituted emergencyultrasound.org.uk

  6. Case 2 • ‘Red call’ • 62 year old man • Hypotension, epigastric pain • Unwell ?AAA • 10 minutes emergencyultrasound.org.uk

  7. Case 2 • BP 74/54, Pulse 110, clammy • Initial resuscitation underway • ACES scan emergencyultrasound.org.uk

  8. No AAA Abdomen emergencyultrasound.org.uk

  9. No free fluid Abdomen emergencyultrasound.org.uk

  10. Abdomen - IVC • Slight collapse on inspiration emergencyultrasound.org.uk

  11. Cardiac - subcostal • No pericardial effusion • Hyperdynamic • Not small • RV not dilated emergencyultrasound.org.uk

  12. CXR • Fluid challenge • IV antibiotics • IJ line (us control) • ICU emergencyultrasound.org.uk

  13. ACES scan • Aim is to help identify the likely cause of hypotension emergencyultrasound.org.uk

  14. Causes of Hypotension • Hypovolaemia • Obstructive (tamponade) • Obstructive (PE) • Cardiogenic • Distributive (septic) emergencyultrasound.org.uk

  15. Hypovolaemia Two aims of ACES scan:- • To establish existence of hypovolaemic state • IVC • ‘collapse index’ • Cardiac • Small chamber size ‘small heart’ • Aggressive wall motion ‘hyperdynamic’ • To identify possible causes • AAA • Free fluid (haemoperitoneum) emergencyultrasound.org.uk

  16. Tamponade Aims of ACES scan to:- • Identify pericardial effusion • Collapse RA/RV during diastole = tamponade emergencyultrasound.org.uk

  17. PE ACES scan aims to identify:- • RV dilatation • RV hypokinesis • Paradoxical septal motion • IVC distension • (Peripheral views for DVT) emergencyultrasound.org.uk

  18. Cardiogenic ACES scan aims to identify gross abnormalities of cardiac:- • Size • Normal • Small • Dilated • Motion • Normal • Hyperdynamic • Hypodynamic Hypodynamic myocardium = cardiogenic emergencyultrasound.org.uk

  19. Sepsis ACES scan aims to identify:- • Hyperdynamic left ventricular function • Hyperdynamic heart has sensitivity of 33% and a specificity of 94% for sepsis Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with non traumatic symptomatic undifferentiated hypotension Jones A et al Shock 2005 Dec;24(6) :513-7 emergencyultrasound.org.uk

  20. ACES scan - 6 windows • Cardiac • IVC • Aorta • RUQ • LUQ • Pelvis emergencyultrasound.org.uk

  21. IVC and collapse index • Relationship between IVC pressure and RA pressure • Identify IVC • Measure in inspiration and expiration • M mode • Calculate ‘collapse index’ emergencyultrasound.org.uk

  22. IVC and collapse index emergencyultrasound.org.uk

  23. Collapse Index • Inspiration – IVC collapses slightly • Expiration – IVC maximal diameter emergencyultrasound.org.uk

  24. Collapse Index (CI) Max diameter – Min diameter CI = x 100% Max diameter Maximum diameter - expiration Minimum diameter - inspiration emergencyultrasound.org.uk

  25. Collapse Index • CI > 50% = RA pressure < 10mmHg • CI < 50% = RA pressure > 10mmHg Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava Kircher BJ et al Am J Cardiol 1990 Aug 15;66(4):493-6 emergencyultrasound.org.uk

  26. ACES scan - subcostal • Pericardial effusion • Gross assessment of cardiac wall motion • Normal • Hypodynamic • Hyperdynamic • Gross assessment of cardiac chamber size emergencyultrasound.org.uk

  27. ACES scan – additional views • Thoracic views – parasternal, apical • Augment subcostal view • (Peripheral views – DVT) emergencyultrasound.org.uk

  28. Summary ACES scan emergencyultrasound.org.uk

More Related