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Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review
© The Author(s). 2016
Received: 17 April 2016
Accepted: 12 July 2016
Published: 15 August 2016
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.
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 , 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
Interpretation of lung ultrasound
Hypoechoic intercostal muscle and echoic ribs with acoustic shadow
Subcutaneous emphysema (E-lines)
Pleural line abnormalities
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 . 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
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 . 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.
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.
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 . 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 . Occasionally, increased resistance of venous return due to a large pleural effusion itself can result in IVC dilation.
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 . 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.
Inferior vena cava
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 .
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 .
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.
A non-diffuse interstitial pattern typically points to a pulmonary origin as a cause of dyspnea, in which lung ultrasound alone is usually sufficient.
Shock or shock-related symptoms or signs
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)
RV failure (PE)
LV outflow tract failure
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 . 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 . 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 .
Diffuse interstitial pattern
Cardiogenic shock is most likely.
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 . 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 . 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 .
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 .
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.
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
The authors would like to acknowledge Dr. Seong-Beom Oh for contributing Fig. 24: apical ballooning syndrome.
No funding to declare.
Availability of data and materials
No new software, databases, or application/tool described in the manuscript.
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.
The authors declare that they have no competing interests.
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