- Review
- Open Access
Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review
- Young-Rock Ha1Email author and
- Hong-Chuen Toh2
- Received: 17 April 2016
- Accepted: 12 July 2016
- Published: 15 August 2016
Abstract
Rapid and accurate diagnosis and treatment are paramount in the management of the critically ill. Critical care ultrasound has been widely used as an adjunct to standard clinical examination, an invaluable extension of physical examination to guide clinical decision-making at bedside. Recently, there is growing interest in the use of multi-organ point-of-care ultrasound (MOPOCUS) for the management of the critically ill, especially in the early phase of resuscitation. This article will review the role and utility of symptom-based and sign-oriented MOPOCUS in patients with undifferentiated respiratory difficulty, chest pain, or shock and how it can be performed in a timely, effective, and efficient manner.
Keywords
- Multi-organ point-of-care ultrasound
- Respiratory difficulty
- Chest pain
- Shock
Background
The capability to recognize and resuscitate the critically ill, or peri-cardiac arrest patients, is one of the defining traits of critical care and emergency medicine. These patients can be categorized into three groups: pre-arrest, intra-arrest, and post-arrest with return of spontaneous circulation (ROSC). For all three groups, and especially the pre-arrest patients, rapid diagnosis of the underlying physiology and etiology and timely intervention are essential for effective management and stabilization. Speedy and accurate clinical decisions can be lifesaving. Traditionally, acute care physicians evaluate patients based on history and physical examinations. For those presenting with respiratory difficulty, chest pain, shock, or shock-related symptoms or signs, the assessment has to be performed in a focused and time-sensitive manner. Now, bedside multi-organ point-of-care ultrasound (MOPOCUS) and MOPOCUS-guided protocols can be used as an adjunct to standard clinical examination, especially during the initial and undifferentiated phase. MOPOCUS can provide many critical pieces of information to guide clinical decision-making, while waiting for laboratory and imaging results.
According to the consensus statement of the American Society of Echocardiography and the American College of Emergency Medicine [1], respiratory difficulty, chest pain, or shock are recommended indications of the focused cardiac ultrasound in an emergency setting. A growing body of evidence also supports the use of MOPOCUS of the critically ill to evaluate cause of shock or dyspnea [2–15]. Although there are only few studies reporting the utility of MOPOCUS using chest pain alone as the primary indication, the astute clinician is cognizant that etiologies classically associated with chest pain, such as acute coronary syndrome and aortic dissection, can be associated with dyspnea or hypotension or even presents atypically with these two “non-cardiac” presentations alone in the absence of chest pain. A patient with pneumothorax can present with shortness of breath and chest pain and develop hypotension when it becomes a tension pneumothorax. Acute myocardial infarction complicated with cardiogenic shock and pulmonary edema can produce dyspnea, chest pain, and shock concurrently. Indeed, the patient’s signs and symptoms can vary depending on the severity of disease and presence of complications. Therefore, it is prudent for acute care physicians to perform a symptom- or sign-based MOPOCUS for any combination of the three indications listed above.
MOPOCUS is a powerful adjunct to clinical assessment. The certainty of presumptive diagnosis derived from history-taking and physical examination can be validated, or occasionally refuted, by information provided by MOPOCUS. In this article, we will appraise the utility of an integrated MOPOCUS, focusing on the differential diagnostic process in pre-cardiac arrest situation and the sequence of scanning. A detailed review of each organ, especially the abdomen, using point-of-care ultrasound (POCUS) will be covered subsequently in this thematic series.
The sequence of MOPOCUS scanning
Sequence of MOPOCUS scanning
The algorithm (Figs. 2, 7, 8, 12, 14, 16, and 19) begins at the top with the primary ultrasound finding or application (extra bold tab) and primary clinical presentation (rectangle) and proceeds downwards. The specific MOPOCUS findings are indicated by the bold tab, while the tab itself represents the diagnosis. The double-lined rectangular frame suggests further ultrasound assessment or clinical intervention. The sequence of assessment and interpretation is guided by the black line behind these icons
Lung ultrasound
Interpretation of lung ultrasound
Location | Normal findings | Abnormal findings |
---|---|---|
Chest wall | Hypoechoic intercostal muscle and echoic ribs with acoustic shadow | Subcutaneous emphysema (E-lines) |
Pleural line | Lung sliding | Lung point |
Lung pulse | Pleural line abnormalities | |
• Irregular | ||
• Thickened | ||
• Fragmented | ||
Supleural space | A-linesa | Multiple B-lines (3 or more per intercostal space) consolidation pleural effusion |
Few or no B-lines (2 or less per intercostal space) |
Do we need to scan the entire lung when performing lung ultrasound? On the one hand, in the interest of rapid assessment, many favor the BLUE protocol described by Dr. Lichtenstein which uses only three points on each chest [16]. Some sampled five to seven points, taken to be representative of the areas covered [12, 17]. In the comprehensive lung ultrasound, all intercostal spaces are scanned. Regardless of the number of sites scanned, five sonographic lung patterns can be distinguished: normal lung pattern, pneumothorax, interstitial syndrome, alveolar consolidation, and pleural effusion. For practical purposes, we can categorize them into “non-diffuse interstitial pattern” (subdivided into normal lung pattern and abnormal non-diffuse interstitial pattern) and “diffuse interstitial pattern.” This review will describe these lung patterns in the context of different clinical situations and integrate them using the concept of MOPOCUS.
Normal lung pattern
Algorithm for normal lung pattern in lung ultrasound. COPD chronic obstructive lung disease, US ultrasound, PNX pneumothorax, DDx differential diagnosis
A-lines. A-lines (arrowheads) are horizontal artifacts generated by the repeated reflection of the ultrasound beam between the pleural line and the probe surface
A normal lung pattern in patients with shock warrants two immediate follow-up actions: the first is to rule out tension pneumothorax and, secondly, to initiate fluid resuscitation based on the Fluid Administration Limited by Lung Sonography (FALLS) protocol [21–23]. Although it has not been validated in shock, non-diffuse interstitial pattern in critically ill patients had a 97 % positive predictive value for a pulmonary artery occlusion pressure of 18 mmHg or less [24]. Apart from tension pneumothorax, a caval and cardiac ultrasound following lung examination will help define the remaining causes of obstructive shock.
The last pearl to note is that chest pain in patients with a normal lung pattern is mostly visceral in nature. The physician should focus the search for the etiology using cardiac and aortic ultrasound.
Pleural diseases
Pneumothorax
Lung point. Alternating seashore sign (left) and stratosphere sign (right) on M mode is pathognomonic for pneumothorax
When the size of the pneumothorax becomes large enough to surround the entire lung surface, the lung point will disappear. Consequently, the acute care physician should not waste time looking for the lung point and thus delay a chest tube insertion, especially when the patient is in shock. In this case, one would expect to find a plethoric IVC on the subxiphoid view, with the heart displaced to the contralateral side. Tension pneumothorax is the first etiology to rule out among the other causes of obstructive shocks.
Pleural effusion
Pleural effusion. Pleural effusion (asterisk) permits the ultrasound beam to penetrate deeply to reveal the vertebral stripe (arrow). The vertebral stripe will not be visible above the diaphragm if the lung is aerated
A large pleural effusion can cause respiratory embarrassment, hypovolemic shock (especially in a large hemothorax), or even obstructive shock due to compression of the IVC and heart, which induces the diastolic failure [31]. In patients who required mechanical ventilation and had a significant transudate pleural effusion, chest tube drainage in addition to standard therapy was reported to result in more rapid discontinuation from mechanical ventilation [32]. Occasionally, increased resistance of venous return due to a large pleural effusion itself can result in IVC dilation.
Parenchymal disease
Interstitial syndrome
Algorithm for diffuse interstitial pattern in lung ultrasound. IVC inferior vena cava, LV left ventricle, ALI acute lung injury, ARDS acute respiratory distress syndrome
Algorithm for abnormal non-diffuse interstitial pattern in lung ultrasound. IS interstitial syndrome, PE pulmonary embolism, IVC inferior vena cava, PNX pneumothorax
B-lines. B-line (arrow) is a bright comet-tail artifact that arises from the pleural line (arrowhead). It will move with lung sliding, if the sliding is present, and extends to the end of the screen without fading
If diffuse IS accompanies shock, the presumptive shock physiology is likely cardiogenic. The physician should try to elucidate the cause using IVC and cardiac ultrasound.
Focal (localized) interstitial sonographic pattern is seen in a variety of pathologies of pulmonary origin, such as pneumonia, atelectasis, pulmonary contusion, pulmonary infarction, pleural disease, or neoplasia [21]. Note that the main difference between diffuse and focal interstitial patterns on ultrasound is that the lung findings on the latter are asymmetrical. In itself, focal IS is not specific for an etiology: physicians need to integrate it in the entire clinical context, including other sonographic findings.
Alveolar consolidation
Lung consolidation. When the lung is consolidated (asterisk), it has a tissue-like appearance. The consolidation also allows penetration of the ultrasound beam, revealing the vertebral stripe (arrow)
Alveolar consolidation and dynamic air bronchogram. Hypoechoic tissue-like patterned consolidation of the right upper lobe. Bright spots or streaky appearances are air bronchogram (arrow). A dynamic air bronchogram is visualized in the real-time image
Inferior vena cava
Algorithm for shock assessment. IVC inferior vena cava, RV right ventricle, LV left ventricle
Inferior vena cava (IVC). IVC (arrow) draining into the right atrium (asterisk)
The presence of diffuse interstitial pattern with dilated and fixed IVC in shock patients prompts the physician to scan the heart, because the cause of shock is likely cardiogenic. Causes of obstructive shock (cardiac tamponade, tension pneumothorax, and PE) resulted in dilated IVC and non-diffuse interstitial pattern of the lung. A large pleural effusion resulting in diastolic failure or pulmonary hypertension caused by hypoxemia/hypercarbia also can lead to IVC plethora [31].
The key decisions for an acute care physician to make in undifferentiated shock depend on the categorization among three fluid management states: fluid resuscitate, fluid challenge, or fluid restrict. Using information from lung and IVC ultrasound, the physician can embark on an action and guide subsequent decision by cardiac ultrasound [46].
Cardiac ultrasound
With information integrated from the preceding lung and IVC assessment, cardiac ultrasound can readily define the etiology of acute dyspnea and shock. It also plays a pivotal role in the case of visceral chest pain. This section describes the utility of cardiac ultrasound in the context of MOPOCUS for dyspnea, chest pain, and shock in turn.
Acute dyspnea
Cardiac ultrasound in respiratory difficulty. PE pulmonary embolism, LV left ventricle, ARDS acute respiratory distress syndrome, PF pulmonary fibrosis, IPn interstitial pneumonia, AR aortic regurgitation, MR mitral regurgitation, Decom. decompensated, MVD mitral valve disease, AVD aortic valve disease, AMI acute myocardial infarction, HF heart failure
Left ventricular hypertrophy. Left ventricular hypertrophy involving both septal and lateral walls (2.14 cm). The left atrial appeared enlarged
A non-diffuse interstitial pattern typically points to a pulmonary origin as a cause of dyspnea, in which lung ultrasound alone is usually sufficient.
Chest pain
Cardiac ultrasound in chest pain. RWMA regional wall motion abnormality, Pn pneumonia, PE pulmonary embolism, PNX pneumothorax, AMI acute myocardial infarction
Thoracic aortic dissection. A moving intimal flap (arrow) in a proximal thoracic is visualized in the real-time image
Abdominal aortic dissection. An intimal flap (arrow) dissecting into the lumen of the abdominal aorta. The arrowhead points to the vertebral stripe, on which the aorta lies
Shock or shock-related symptoms or signs
Cardiac ultrasound in shock. IVC inferior vena cava, LV left ventricle, RV right ventricle, LVOT left ventricular outflow tract, PE pulmonary embolism, AMI acute myocardial infarction, HCMP hypertrophic cardiomyopathy, MR mitral regurgitation, AR aortic regurgitation, Decomp. decompensated, MS mitral stenosis, AS aortic stenosis
Non-diffuse interstitial pattern
It is suggestive of obstructive or hypovolemic shock: IVC plethora indicates obstructive shock, while a small non-plethoric IVC is usually associated with hypovolemic shock.
Pericardial failure (cardiac tamponade)
Cardiac tamponade. Right-sided heart chambers collapsed (arrow), due to increased intrapericardial pressure from a large pericardial effusion (asterisk)
Cardiac tamponade physiology. (Left) Cardiac tamponade physiology, demonstrating reduced and aggravated variation of mitral valve inflow velocity. (Right) Post-pericardiocentesis: significant improvement in mitral valve inflow velocity
RV failure (PE)
D-shaped left ventricle. The interventricular septum is normally round and bulges into the right ventricle (RV) throughout the cardiac cycle. Increased RV pressure causes the septum to be deformed to assume a “D”-shaped left ventricle (arrow)
Pulmonary embolism, severe. Right ventricular enlargement (more than 0.9 of left ventricular size) is demonstrated (white asterisk). The RV free wall does not appear thickened, indicating an acute RV failure
LV outflow tract failure
Apical ballooning syndrome. Severe hypokinesia of mid-ventricle sparing the basal segments (arrow). This is better appreciated during real-time scanning. Courtesy of Dr. Seong-Beom Oh
Other useful LV findings in shock states not caused by LV itself
After excluding obstructive shocks by information from sonographic findings of the lung, IVC, pericardium, and RV, the physician then needs to pay attention to the LV. Hyperdynamic LV without other abnormalities including significant valvular pathology suggests either distributive or hypovolemic shock. Distributive shock and hypovolemic shock commonly coexist in the critically ill, and early recognition and treatment with fluid resuscitation are paramount to manage these patients [49]. Therefore, we can practically categorize both as hypovolemic shock. It can be subdivided into absolute (hypovolemic) and relative (distributive) hypovolemic shock. Absolute hypovolemic shock has small-sized LV, while relative hypovolemic shock has normal-sized LV [31]. Jones et al. reported the presence of hyperdynamic left ventricular function (EF > 55 %) in emergency department patients with non-traumatic shock is highly specific for sepsis as the etiology of shock [68].
Diffuse interstitial pattern
Cardiogenic shock is most likely.
LV failure
MI with LV failure remains the most common cause of cardiogenic shock. The SHOCK trial registry demonstrated that predominant LV failure was the most common cause of cardiogenic shock, occurring in 78.5 % of patients. Patients with predominant LV failure complicating acute MI were more likely to have an anterior MI. Inferior MI was less often associated with LV failure but associated with a greater risk of mechanical complications [69]. Therefore, the presence of an extensive anterior MI or mechanical complications (severe MR due to papillary muscle rupture, ventricular septal defect, tamponade secondary to cardiac rupture, etc.) is a major concern in this setting [70]. In these settings, cardiac ultrasound is the investigation of choice. The clinical presentations of myopericarditis, apical ballooning syndrome, and hypertrophic cardiomyopathy can be similar to ACS and even cardiogenic shock. Sonographic findings of apical ballooning syndrome is a moderate-to-severe mid-ventricular dysfunction and apical akinesia with preserved basal function [71].
Valve failure
Flailed mitral valve. Flailed posterior mitral leaflet (arrow). Note the presence of a small pericardial effusion (arrowhead) and larger left pleural effusion (asterisk)
Abdominal ultrasound
Abdominal ultrasound can help to determine the cause of hypovolemic (both absolute and relative) shock. Intra-abdominal source of blood loss or infection such as peritoneal effusion, ruptured abdominal aortic aneurysm or ectopic pregnancy, liver/spleen abscess, cholecystitis, cholangitis, or pyonephritis can be visualized [74].
Conclusions
Multi-organ point-of-care ultrasound is a powerful adjunct to standard clinical assessment. It provides critical and timely information in the evaluation of patients presenting with acute dyspnea, chest pain, or shock: when and where it matters most, right at the bedside. It has become an indispensable part of the acute care physician’s armamentarium, in the battle for our patients’ lives.
Abbreviations
ACS, acute coronary syndrome; ARDS, adult respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; CT, computerized tomography; ECG, electrocardiography; FALLS, Fluid Administration Limited by Lung Sonography; IS, interstitial syndrome; IVC, inferior vena cava; LV, left ventricle or left ventricular; MOPOCUS, multi-organ point-of-care ultrasound; MR, mitral regurgitation; PE, pulmonary embolism; POCUS, point-of-care ultrasound; ROSC, return of spontaneous circulation; RV, right ventricle or right ventricular; RWMA, regional wall motion abnormality
Declarations
Acknowledgements
The authors would like to acknowledge Dr. Seong-Beom Oh for contributing Fig. 24: apical ballooning syndrome.
Funding
No funding to declare.
Availability of data and materials
No new software, databases, or application/tool described in the manuscript.
Authors’ contributions
YRH conceived the review, performed the literature search, and wrote the first draft of this paper. HCT revised the manuscript. Both authors contributed to the figures, read, and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Authors’ Affiliations
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