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

2. emergencyultrasound.org.uk A bdominal A bdominal(and) C ardiac C ardiac E valuation E valuation (with sonography in) S hock S hock The ACES scan

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

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

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

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

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

8. emergencyultrasound.org.uk Abdomen No AAA No AAA

9. emergencyultrasound.org.uk Abdomen No free fluid No free fluid

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

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

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

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

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

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

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

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

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

19. emergencyultrasound.org.uk Sepsis ACES scan aims to identify:- Hyperdynamic left ventricular function Hyperdynamic left ventricular function Hyperdynamic heart has sensitivity of 33% and a specificity of 94% for sepsis 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

20. emergencyultrasound.org.uk ACES scan - 6 windows 1. Cardiac 2. IVC 3. Aorta 4. RUQ 5. LUQ 6. Pelvis

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

22. emergencyultrasound.org.uk IVC and collapse index

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

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

25. emergencyultrasound.org.uk Collapse Index CI > 50% = RA pressure 50% = RA pressure < 10mmHg CI 10mmHg CI 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

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

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

28. emergencyultrasound.org.uk Summary ACES scan