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1、重症超声的临床应用重症超声的临床应用重症超声的临床应用l 重症患者病情危重l 有创操作多l 易于发生病情变化，需要及 时发现、判断和处理l 超声便捷、无创、及时、可重复、可视u 床旁超声走向重症患者重症超声的临床应用l 循环功能和容量状态判断：复苏超声u 肺部超声：Blue流程u 血管定位和穿刺：u 创伤的快速探查u 气道评估和定位Echocardiography is now an unavoidable tool in assessing hemodynamic instability in the ICU. Echocardiography training is crucial to
2、help its widespread use in all ICUs.休克复苏超声休克复苏超声Case 1l 72yr，男性， 因发热、咳嗽伴胸痛就诊l BP 82/60mmHg, HR 120次/分, RR 24次/分,T 38.6, SpO2 92%l 双肺底细湿罗音l心电图左束支传导阻滞l 胸片：双下肺少量渗出 无气胸、纵隔增宽和心影增大5Case 2l 64yr，女性，气促伴胸痛入院l 既往有乳腺癌病史，近三年稳定l T 98F, Bp74/58 mmHg , HR120次/分, RR30 次/分，SpO2 94% l 颈静脉充盈，心音减低，双肺底少量湿罗音l EKG：低电压l 胸片
3、：心影增大、双肺散在渗出影 6Discussionl Shockl Case 1：l 重症肺炎，感染性休克l ACS？肺栓塞？主动脉夹层？l 补液量？容量反应性？l Case 2：l 心包填塞，梗阻性休克l 心包穿刺？l 肺栓塞？溶栓？7l 血流动力学监测l 影像学检查Discussionl Bedside UltrasoundBedside Ultrasound in Resuscitation and The Rapid Ultrasound In Shock Protocol (RUSH)Emergency Medicine Clinics of North America , 2010
4、(28): 2956Ultrasound Clinics, 2012(7): 2552788休克复苏的超声应用l心脏泵功能l容量状态Critical Care Research and Practice, 20129The pump： Cardiac statusl A goal-directed echocardiogram: A：Left ventricular contractility B：Right ventricular dilatio C：Pericardial effusion10A：left ventricular contractility Good left ventri
5、cular contractilityFractional shortening=(EDD ESD)/EDD 10030%45% FS correlates to normal EFAcademic Emergency Medicine, 2011: 912921 11Poor left ventricular contractility12Global left ventricular hypokinesia is very frequentin adult septic shock and could be unmasked, in some patients, by norepineph
6、rine treatment (the overall incidence of global LV hypokinesia was 60%). LVFAC 24%Crit Care Med 2008; 36:17011706左心收缩功能定性评价左心收缩功能定性评价n节段性室壁运动异常n室壁瘤的形成lRV enlargement: dysfunctionlSmall changes in pressure result in large changes in ventricular volumel left-to-right Ventricleis 1 : 0 .6B：right ventri
7、cular dilationEur Heart J 1996;17:77986.15B：right ventricular dilation16C：Signs of tamponade17C：pericardial effusionsSubxiphoid cardiac viewLeft image: typical effusion, right image: clotted effusion18RUQ free fluid. Coronal view of the RUQshowing free fluidLUQ free fluid. Coronal view of the LUQfre
8、e fluid surrounding the spleen19Pelvic free fluidFree fluid in the rectovesicular space 20A：Fullness of the TankA position approximately 2cm from the junction of the right atrium and the IVCI VC diameter 50% with sniff CVP 3 mmHg ( range 0 5 mmHg)Journal of the American Society of Echocardiography , 2010, 23: 68571321A larger IVC 2 cm that collapses3.8 cmA：Rupture of the PipesEur J Echocardiogr 2009;10:i319.Others 气管切开局部解剖观察 膈肌活动度 肾血管阻力指数 重症超声重症医学工作者的得力助手开辟新的领域重症医学走得更远
