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Integrating ultrasound in emergency prehospital settings

As previous and future chapters will attest, ultrasonography (US) is an indispensable modality in assessing patients in the hospital and outpatient setting. In the past few years, compact, robust, and portable US machines have been developed for use in various prehospital settings. Recent technologic advances have led to the development of battery-powered, light, handheld portable devices. In addition, ease of use, simplification of technology, and facilitated…

Ultrasound in the neonatal and pediatric intensive care unit

Overview Children and neonates are ideal candidates for the implementation of the holistic approach (HOLA) critical care ultrasound concept (see Chapter 1 ). This is mainly due to their small body size, which permits the fast application of all possible ultrasound techniques from head to toe. However, in the individual pediatric patient, only a part of the available ultrasound techniques will be clinically indicated, and many…

Use of ultrasound in the evaluation and treatment of intraabdominal hypertension and abdominal compartment syndrome

Overview Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are well-documented causes of morbidity and mortality in the critically ill. IAH and ACS may affect almost every organ system. The World Society of the Abdominal Compartment Syndrome ( www.wsacs.org ) has set forth a number of definitions based on clinical evidence and expert opinion. Intraabdominal pressure (IAP) is normally 5 to 7 mm Hg in adults.…

The extended fast protocol

Overview Ultrasound has become a permanent part of the evaluation of trauma patients ever since its first use in the emergency department more than 30 years ago. First used in Europe in the 1970s, abdominal ultrasound ultimately replaced diagnostic peritoneal lavage during the 1980s. Currently, bedside ultrasound is the initial imaging modality of choice for trauma care and is integrated into the Advanced Trauma Life Support…

Procedural ultrasound for surgeons: (CONSULTANT-LEVEL EXAMINATION)

Ultrasound (US) has become an indispensable part of the surgeon’s armamentarium, useful in both bedside assessment and operative treatment. Because the diagnostic and critical care applications of US are discussed elsewhere, this chapter will focus on intraoperative and US-guided surgical procedures. Intraoperative ultrasonography Intraoperative ultrasonography (IOUS) has been described extensively since the 1980s, and although its main applications are in hepatobiliary and pancreatic surgery, it also…

Point-of-care pelvic ultrasound

Overview This chapter illustrates the basic features of pelvic ultrasound by outlining the exploration of the female genital system, concluding thus the holistic approach (HOLA) ultrasound concept of the abdominal examination (see Chapters 1 and 44 ). Clinician-performed point-of-care pelvic ultrasound is an integral skill in a growing number of medical subspecialties. History and physical examination are not always reliable in the evaluation of possible pelvic…

Approach to the urogenital system

Anatomy The oval-shaped kidneys, measuring 9 to 15 cm in length and 4 to 6 cm in width, are located in retroperitoneum between the 12th thoracic and 4th lumbar vertebrae, just lateral to the psoas muscles. The kidneys are surrounded by the Gerota fascia (echogenic capsule) and a fat layer of variable thickness. Ultrasound examination, in both longitudinal and transverse planes, is performed using convex or…

Various targets in the abdomen (hepatobiliary system, spleen, pancreas, gastrointestinal tract, and peritoneum): (CONSULTANT-LEVEL EXAMINATION)

Overview Abdominal ultrasound can be used to obtain images of the hepatobiliary, urogenital, and pelvic structures. The approach to the urogenital system, point-of-care pelvic ultrasound, focused assessment with sonography for trauma, and other subjects are discussed in Chapter 42, Chapter 43, Chapter 44, Chapter 45, Chapter 46 . In this chapter, examination of various abdominal targets such as the hepatobiliary system, spleen, pancreas, gastrointestinal (GI) tract,…

Perioperative sonographic monitoring in cardiovascular surgery

Overview Despite the well-known advances in cardiovascular surgery over the last 50 years, it remains a high-risk procedure associated with significant morbidity and mortality rates. Currently, patients undergoing cardiovascular operations tend to be older and have more comorbid conditions. This could be attributed to the progress in surgical procedures, as well as to improved preoperative, perioperative, and postoperative care, which includes hemodynamic optimization by implementation of…

Ultrasonography in circulatory failure

Overview Shock is an emergency medical condition caused by inadequate tissue oxygenation. Treatment of shock depends on the underlying cause of the circulatory failure. Ultrasound facilitates rapid evaluation of hemodynamically unstable patients by providing valuable information about not only myocardial function but also the peripheral vasculature. When performed in real time, intensivist-guided bedside ultrasonography can be used to differentiate between shock states, facilitate efficient early goal-directed…

Evaluation of fluid responsiveness by ultrasound

Overview Fluid therapy is the cornerstone of hemodynamic resuscitation, and its aim is to increase tissue perfusion. Notably, a positive fluid balance is associated with a poor outcome. Thus it is important to optimize fluid administration and identify patients who may most benefit from it while trying to predict fluid responsiveness. Fluids increase tissue perfusion by means of an increase in cardiac output (CO), which is…

Measures of volume status in the intensive care unit

Overview Prescribing fluid therapy is a common therapeutic dilemma in the intensive care unit (ICU); however, different methods of evaluating volume status are available to guide this decision. This chapter discusses these methods briefly. Fluid therapy is of critical importance in the treatment of patients in shock since it may result in improved tissue perfusion and organ function. Administration of fluids is a key feature of…

Hemodynamic monitoring considerations in the intensive care unit

Overview In critical care, the goals of hemodynamic monitoring include mainly detection of cardiovascular insufficiency and diagnosis of the underlying pathophysiology. At the bedside, clinicians are faced with the challenge of translating concepts such as preload, contractility, and afterload into determinants of stroke volume and hence cardiac output. Ultrasound and echocardiography offer unique insight into ventricular filling and systolic function. In recent years there has been…

Improving cardiovascular imaging diagnostics by using patient-specific numerical simulations and biomechanical analysis

Overview Ultrasound is the only imaging modality, apart from magnetic resonance imaging (MRI), that provides real-time functional and structural information on the beating heart. However, modeling moving cardiovascular structures is a complex process that requires three- dimensional (3D) reconstruction of two-dimensional (2D) data by fast imaging techniques (e.g., MRI) to thus yield dynamic four-dimensional (4D) views of cardiovascular pulsations. The unique 3D geometry of the cardiovascular…

Evaluation of patients at high risk for weaning failure with doppler echocardiography: (CONSULTANT LEVEL EXAMINATION)

Overview Weaning failure is a major complication of mechanical ventilation with associated morbidity and mortality. It is usually defined as an unsuccessful spontaneous breathing trial (SBT) or need for tracheal reintubation within 48 hours following extubation. According to study populations and diagnostic criteria, the incidence of weaning failure ranges from 25% to 42% in large cohorts. Although the mechanisms are varied and potentially complex, failure to…

Evaluation of right ventricular function in the intensive care unit by echocardiography: (CONSULTANT-LEVEL EXAMINATION)

Overview Assessment of right ventricular (RV) function is a key element in the hemodynamic evaluation of patients in the intensive care unit (ICU) with shock or respiratory failure. , For several decades the former was considered to play a minor role in hemodynamic failure. However, RV dysfunction may be a crucial element in the hemodynamic compromise that intensivists encounter in various clinical scenarios such as pulmonary…

Evaluation of left ventricular diastolic function in the intensive care unit: (CONSULTANT-LEVEL EXAMINATION)

Overview Left ventricular (LV) diastolic dysfunction is a clinical entity that remains poorly understood and identified in the intensive care unit (ICU) setting. It is essential to clarify the difference between diastolic heart failure, LV diastolic dysfunction, and increased LV filling pressure. Diastolic heart failure is a clinical syndrome defined by the presence of symptoms of congestive heart failure in the setting of diastolic dysfunction (and…

Echocardiography in cardiac arrest

Overview The incidence of out-of-hospital cardiac arrest is estimated to be 50 to 55 per 100,000 in the United States. When a primary electrical cause of cardiac arrest is found, definitive treatment is directed toward reversing the rhythm disturbance (cardioversion, defibrillation, pacing). When a nonelectrical cause of cardiac arrest is diagnosed (pulseless electrical activity [PEA]/asystole), practitioners are urged to exclude and treat potentially reversible causes because…

Echocardiography in cardiac trauma

Overview Cardiac injury as a result of blunt or penetrating chest trauma is common and associated with significant morbidity and mortality. Approximately 25% of traumatic deaths are caused by cardiac-related injuries, with the majority involving either cardiac or great-vessel damage. Most penetrating cardiac wounds are immediately fatal. For those arriving at the hospital alive, focused assessment with sonography for trauma (FAST) and transthoracic echocardiography (TTE) are…

Transesophageal echocardiography

Overview After development of an esophageal stethoscope, the first transesophageal echocardiographic (TEE) equipment provided simple M-mode images to measure left ventricular (LV) dimensions. First used for intraoperative monitoring of LV function and intracardiac air more than 30 years ago, TEE is now widely considered the standard of care for a number of cardiac surgical procedures. , In parallel with transthoracic echocardiography (TTE), development of phased-array transducers;…