1、急诊超声对于休克患者的鉴别诊急诊超声对于休克患者的鉴别诊断断(刘继海刘继海)急诊超声和普通超声的区别？以不明原因休克患者RUSH检查为例进一步阐释急诊超声的重要性急诊超声的未来发展方向？“争地盘”或“抢饭碗”该不该做？“资质问题”与“收费问题”如何做？“难做吗”与“做得准吗”培训与质量控制如何解决？急诊医生床旁超声检查旨在最短的时间内得到明确的诊断线索（带着问题进行超声检查）:患者各浆膜腔有液体吗?患者有腹主动脉瘤吗?患者有宫内妊娠吗?患者有深静脉血栓吗?患者的心脏在收缩吗?正常还是异常?表2.1 CCEP急诊超声基本应用 2013创伤超声重点评估腹主动脉超声重点评估心脏急诊重点超声超声引导操
2、作技术气道急诊超声评估表2.2 CCEP急诊超声高级应用 2013肺急诊重点评估外周血管急诊重点评估腹部急诊重点评估妇产科急诊重点评估阴囊急诊评估眼睛急诊评估危重患者的快速有针对性的超声检查，提高诊断效率:FAST,AAA,Cardiac in PEA or hypotension改进患者的流程，减少急诊滞留时间:DVT,Pelvic sono in early pregnancy帮助我们完成一些操作，降低风险:Central lines,abscesses,LPs传统的超声检查更加注重某个脏器病变的检查和描述，急诊超声则从临床出发，有目的的对急诊患者进行超声的重点扫查，对于患者的疾病状态和脏
3、器功能状况做出更为直观的评价，并根据检查的结果对患者进一步治疗和处置提出指导意见。由急诊医师主导的超声检查技术，被誉为“急诊医师的可视听诊器”评估危重症患者病情、对于危及生命的急诊疾病做出快速的诊断提高了急诊患者的诊治效率 引导临床侵入性操作及指导相关急诊状况的处置等，有效降低了侵入性操作并发症的发生率24岁女性，58公斤，既往健康，仅口服避孕药。因“晕倒”被急救车送入院。病人意识模糊，病史有限。GCS（格拉斯哥昏迷评分）5-6，BP 73/42，脉搏80次/分，体温38.3，SpO292%（在吸氧4升/分钟的情况下），呼吸26次/分，大汗，右小腿及脚部明显肿胀。胸片无明显异常。心电图窦性心律
4、，血糖4.3mM/L。Left ventricular failureTension pneumothoraxHemoperitoneumAnaphylaxisSevere dehydrationNeurogenic shockCardiac tamponadeValvular dysfunctionPulmonary embolusOccult medication error or overdoseSepsisRuptured aneurysmAortic dissectionMyocardial ischemia/infarctionThyrotoxicosisAdrenal failu
5、reDysrhythmiaAutonomic dysfunctionOccult gastrointestinal bleedMesenteric ischemiaAbdominal inflammationThis technology is ideal in the care of the critical patient in shock,and the most recent ACEP guidelines further delineate a new category of resuscitative ultrasound.Step 1:The pump（泵）Step 2:The
6、tank（血容量）Step 3:The pipes（血管）Effusion around the pump:evaluation of the pericardiumSqueeze of the pump:determination of global left ventricular functionStrain of the pump:assessment of right ventricular strainLateral wallLateral wallAnterior walldetermination of how strong the pump is?”a visual calc
7、ulation of the percentage change from diastole to systoleMotion of anterior leaflet of the mitral valve can also be used to assess contractility.Lateral wallTo judge the strength of contractions as good,with the walls of the ventricle contracting well during systole;Poor,with the endocardial walls c
8、hanging little in position from diastole to systole;Intermediate,with the walls moving with a percentage change in between the previous 2 categories.Knowing the strength of left ventricular contractility will give the EP a better idea of how much fluid the pump or heart of the patient can handle,bef
9、ore manifesting signs and symptoms of fluid overload.In cardiac arrest,the clinician should specifically examine for the presence or absence of cardiac contractions.On bedside echocardiography,the normal ratio of the left to right ventricle is 1:0.6.The optimal cardiac views for determining this rat
10、io of size between the 2 ventricles are the parasternal long and short-axis views and the apical 4-chamber view.Massive PESmaller and recurrent pulmonary emboliCor pulmonalePrimary pulmonary artery hypertensionAcute right heart strain thus differs from chronic right heart strain in that although bot
11、h conditions cause dilation of the chamber,the ventricle will not have the time to hypertrophy if the time course is sudden.Evaluation of the pipes”Fullness of the tank:evaluation of the inferior cava and jugular veins for size and collapse with inspirationLeakiness of the tank:FAST exam and pleural
12、 fluid assessmentTank compromise:pneumothoraxTank overload:pulmonary edemaA smaller caliber IVC(2 cm diameter)that collapses less than 50%with inspiration correlates to a CVP of more than 10 cm of water。This phenomenon may be seen in cardiogenic and obstructive shock states.The first is in patients
13、who have received treatment with vasodilators and/or diuretics prior to ultrasound evaluation in whom the IVC may be smaller than prior to treatment,altering the initial physiological state.The second caveat exists in intubated patients receiving positive pressure ventilation,in which the respirator
14、y dynamics of the IVC are reversed.FAST exam and pleural fluid assessmentIn traumatic conditions,as a result of a hole in the tank,leading to hypovolemic shock.In nontraumatic conditions,accumulation of excess fluid into the abdominal and chest cavities often signifies tank overload,In infectious st
15、ates,pneumonia may be accompanied by a complicating parapneumonic pleural effusion,and ascites may lead to spontaneous bacterial peritonitis.To assess for pulmonary edema with ultrasound,the lungs are scanned with the phased-array transducer in the anterolateral chest between the second and fifth ri
16、b interspaces.The presence of B lines coupled with decreased cardiac contractility and a plethoric IVC on focused sonographic evaluation should prompt the clinician to consider the presence of pulmonary edema and initiate appropriate treatment.Rupture of the pipes:aortic aneurysm and dissectionClogg
17、ing of the pipes:venous thromboembolismA measurement of greater than 3 cm is abnormal and defines an abdominal aortic aneurysmThe parasternal long-axis view of the heart permits an evaluation of the proximal aortic root,and a measurement of more than 3.8 cm is considered abnormal.24岁女性，58公斤，既往健康，仅口服
18、避孕药。因“晕倒”被急救车送入院。病人意识模糊，病史有限。GCS（格拉斯哥昏迷评分）5-6，BP 73/42，脉搏80次/分，体温38.3，SpO292%（在吸氧4升/分钟的情况下），呼吸26次/分，大汗，右小腿及脚部明显肿胀。胸片无明显异常。心电图窦性心律，血糖4.3mM/L。心脏收缩力好，未见明显心包积液，无右室劳损表现；下腔静脉直径50%，无浆膜腔积液主动脉正常，下肢静脉未见血栓，右下肢腹股沟区明显红肿右下肢蜂窝织炎，感染性休克右下肢蜂窝织炎，感染性休克心脏收缩力好，未见明显心包积液，无右室劳损表现；下腔静脉直径50%，盆腔积液，超声引导下穿刺抽出不凝血主动脉正常，下肢静脉未见血栓宫外孕破裂出血宫外孕破裂出血心脏收缩力好，未见明显心包积液，可见右室扩大表现，右室心肌不肥厚；下腔静脉直径=2cm，吸气变异率50%，未见多浆膜腔积液表现主动脉正常，下肢静脉可见血栓大面积肺栓塞可能大面积肺栓塞可能超声技术的发展带来变革更加注重脏器功能连续评估被越来越多的急诊医师所掌握并指导临床
