2014-重症超声的临床应用

休克复苏超声Case172yr，男性，因发热、咳嗽伴胸痛就诊BP82/60mmHg,HR120次/分,RR24次/分,T38.6℃,SpO292%双肺底细湿罗音心电图左束支传导阻滞胸片：双下肺少量渗出无气胸、纵隔增宽和心影增大5Case264yr，女性，气促伴胸痛入院既往有乳腺癌病史，近三年稳定T98F,Bp74/58mmHg,HR120次/分,RR30次/分，SpO294%颈静脉充盈，心音减低，双肺底少量湿罗音EKG：低电压胸片：心影增大、双肺散在渗出影6DiscussionShockCase1：重症肺炎，感染性休克ACS？肺栓塞？主动脉夹层？补液量？容量反应性？Case2：心包填塞，梗阻性休克心包穿刺？肺栓塞？溶栓？7血流动力学监测影像学检查DiscussionBedsideUltrasoundBedsideUltrasoundinResuscitationandTheRapidUltrasoundInShockProtocol(RUSH)EmergencyMedicineClinicsofNorthAmerica,2010(28):29–56UltrasoundClinics,2012(7):255–2788休克复苏的超声应用心脏泵功能容量状态CriticalCareResearchandPractice,20129Thepump：CardiacstatusAgoal-directedechocardiogram:A：LeftventricularcontractilityB：RightventriculardilatioC：Pericardialeffusion10A：leftventricularcontractilityGoodleftventricularcontractilityFractionalshortening=[(EDD−ESD)/EDD]×10030%–45%FScorrelatestonormalEFAcademicEmergencyMedicine,2011:912–92111Poorleftventricularcontractility12Globalleftventricularhypokinesiaisveryfrequentinadultsepticshockandcouldbeunmasked,insomepatients,bynorepinephrinetreatment(theoverallincidenceofglobalLVhypokinesiawas60%).LVFAC24%CritCareMed2008;36:1701–1706左心收缩功能定性评价节段性室壁运动异常室壁瘤的形成RVenlargement:dysfunctionSmallchangesinpressureresultinlargechangesinventricularvolumeleft-to-rightVentricleis1:0.6B：rightventriculardilationEurHeartJ1996;17:779–86.15B：rightventriculardilation16C：Signsoftamponade17C：pericardialeffusionsSubxiphoidcardiacviewLeftimage:typicaleffusion,rightimage:clottedeffusion18RUQfreefluid.CoronalviewoftheRUQshowingfreefluidLUQfreefluid.CoronalviewoftheLUQfreefluidsurroundingthespleen19PelvicfreefluidFreefluidintherectovesicularspace20A：FullnessoftheTankApositionapproximately2cmfromthejunctionoftherightatriumandtheIVCIVCdiameter2cmcollapses50%withsniffCVP3mmHg(range0–5mmHg)JournaloftheAmericanSocietyofEchocardiography,2010,23:685–71321AlargerIVC2cmthatcollapses50%withsniffsuggestsahighCVPpressureof15mmHgJournaloftheAmericanSocietyofEchocardiography,2010,23:685–71322Intubatedpatients,theIVCbecomeslargerandlesscompliant23EchocardiographicindicesofvolumeresponsivenessIntensiveCareMed,1995,21:291–295Chest,1999,116:1354–1359Chest,2001,119:867–87324超声对容量状态的评估-低血容量乳头肌亲吻征•包括9个相关研究，其中6个研究应用了超声技术IntensiveCareMed,2010,36:1475–1483FocusedAssessmentofSonographyfor•Trauma(FAST)HemoperitoneumHemothoraxRuptured•ectopicpregnancyLeakinessoftheTank27RUQfreefluid.CoronalviewoftheRUQshowingfreefluidLUQfreefluid.CoronalviewoftheLUQfreefluidsurroundingthespleen28PelvicfreefluidFreefluidintherectovesicularspace29肺部超声PneumothoraxInterstitialsyndromeAlveolarconsolidationPleuraleffusionThepleurallineisdrawnbyonlytheparietalpleura-thereispureairbehindthepleuralline.ThisyieldsAlines.Theabsenceofvisceralpleurayieldsabsenceofdynamic,yieldingthestratospheresign.Normallungsurface:thedynamicofthepleuragenerateslungsliding.ThenormalsubpleuralinterlobularseptaaretoofineforgeneratingBlines-thevisceralpleuracontainsalayerofcells,i.e.,mainly,finecontentsoffluid.Thickenedsubpleuralinterlobularseptawhicharesurroundedbyalveolarair.Thebeamistrappedinthissmallsystemincludingminimequantityoffluid(dimensionsinferiortothatofultrasoundresolution)betweenalveolarair.ThisgeneratesBlines.Numerousalveoliarefilledwithfluid(transudate,exsudate,pus,...).The(deep)interlobularseptaareheresurroundedbyfluid(comet-tailartifactscannotbegenerated).Theseptagenerateinterfacesresultinginatissue-likepattern.Thetwolayersofthepleuraareseparatedbyfreefluid-resultinginhomogeneouspattern(oftenanechoic).Notetheregularlunglineairairairairairairair(Air-fluidratio)AIR/nofluidAIR/fluidAIR/fluidair/FLUIDnoair/FLUID10.980.950.20NormallungsurfaceAthmaCOPD正常肺超声airairair超声波胸膜胸膜滑动，lungslidingA线蝙蝠征胸膜线二维超M超海岸征：Seashoresignlungpulse肺水肿时超声影像airairairB线•B线7个特征:起源于胸膜线高回声影像表现容易发现分布范围广随呼吸节律移动相应区域A线消失慧尾征型伪像超声波肺实变的超声特征•肺泡内充填渗出液、脓液等•超声影像：实质性器官样改变胸腔积液的超声影像肺部病变超声-Interstitialsyndrome•B+lines:•ThreeormoreBlines•inasingleviewPleuraleffusionandalveolarconsolidation;typicalexampleofPLAPS(Posterolateralalveolarand/orpleuralsyndrome)Thequadsign,Thesinusoidsign;Theshredsign气胸时超声影像airairair超声波胸膜A线蝙蝠征M超：Stratospheresign胸膜线气胸超声确诊：肺点(LungPoint)气胸诊断流程•(1)除外气胸征象：•可见胸膜线及胸膜滑动征•可见海岸征•可见lungpulse•可见B线•(2)怀疑气胸•胸膜滑动征消失•M超显示平流征•(3)与气胸征象鉴别的其他情况•皮下气肿•胸膜粘连•肺气肿•肺顺应性显著降低•(4)确诊气胸•看到肺点41Sensitivities:86%to100Specificities:92%to100%Theaveragetime:ultrasoundwas2.3minuteschestradiography19.9minutes超声与平片诊断气胸的比较CritCare2006;10:R112.BLUE:BedsideLungUltrasoundinEmergency重症超声在肺部疾病中的诊断流程血管穿刺置管超声常规体表定位法疾病导致的解剖畸形体位受限血管解剖变异右侧颈内静脉和动脉的解剖关系1%4.5%22.5%49.8%22.2%置管并发症•动脉损伤、局部血肿、严重出血•气胸、血胸•神经损伤•胸导管损伤•感染•……方式•超声引导的导管置入术（Ultrasound-guidedcannulation）•超声辅助的导管置入术（Ultrasound-assistedcannulation）•超声确认血管内导管的位置（Ultrasoundverificationofintravascularplacement）确定静脉的方法V管壁薄，容易被压迫A管壁厚，有弹性，不容易被压迫V和A彩色多普勒探头按压•超声横断面引导法和纵段面引导法颈内静脉短轴图像颈内静脉长轴图像横断面引导法（平面外引导法）纵断面引导法（平面内引导法）Short-axisLong-axis注意：穿刺时针头路径；针头压迫后静脉塌陷；容易直接穿进动脉内探头无菌探头支架，控制进针方向减少压迫导致的血管塌陷超声引导下纵断面穿刺法（平面内）•定位目标血管•寻找截面积最大的平面（截面是血管中间）•穿刺点位于靠近探头的皮肤•穿刺时移动针尖而不是移动探头•必须保证血管一直在屏幕上超声引导下横断面穿刺法（平面外）•定位目标血管•把目标血管至于屏幕中间•穿刺点位于靠近探头的皮肤•使