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The ACES scan. Ultrasound in hypotension Richard Kendall Paul Atkinson. The ACES scan. A bdominal (and) C ardiac E valuation (with sonography in) S hock. The ACES scan. Extension of more established emergency medicine uses of ultrasound Abdominal component Cardiac component

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the aces scan
The ACES scan

Ultrasound in hypotension

Richard Kendall

Paul Atkinson

emergencyultrasound.org.uk

the aces scan2
TheACES scan
  • Abdominal

(and)

  • Cardiac
  • Evaluation

(with sonography in)

  • Shock

emergencyultrasound.org.uk

the aces scan3
The ACES scan
  • Extension of more established emergency medicine uses of ultrasound
  • Abdominal component
  • Cardiac component
  • (Peripheral component)

emergencyultrasound.org.uk

case 1
Case 1
  • ‘Red call’
  • Elderly female – collapsed and absent radial pulse
  • Arrives – peri-arrest
  • Groaning
  • Initial resuscitation
  • ACES scan

emergencyultrasound.org.uk

case 15
Case 1
  • Huge AAA, tender
  • Terminal care instituted

emergencyultrasound.org.uk

case 2
Case 2
  • ‘Red call’
  • 62 year old man
  • Hypotension, epigastric pain
  • Unwell ?AAA
  • 10 minutes

emergencyultrasound.org.uk

case 27
Case 2
  • BP 74/54, Pulse 110, clammy
  • Initial resuscitation underway
  • ACES scan

emergencyultrasound.org.uk

abdomen
No AAAAbdomen

emergencyultrasound.org.uk

abdomen9
No free fluidAbdomen

emergencyultrasound.org.uk

abdomen ivc
Abdomen - IVC
  • Slight collapse on inspiration

emergencyultrasound.org.uk

cardiac subcostal
Cardiac - subcostal
  • No pericardial effusion
  • Hyperdynamic
  • Not small
  • RV not dilated

emergencyultrasound.org.uk

slide12
CXR
  • Fluid challenge
  • IV antibiotics
  • IJ line

(us control)

  • ICU

emergencyultrasound.org.uk

aces scan
ACES scan
  • Aim is to help identify the likely cause of hypotension

emergencyultrasound.org.uk

causes of hypotension
Causes of Hypotension
  • Hypovolaemia
  • Obstructive (tamponade)
  • Obstructive (PE)
  • Cardiogenic
  • Distributive (septic)

emergencyultrasound.org.uk

hypovolaemia
Hypovolaemia

Two aims of ACES scan:-

  • To establish existence of hypovolaemic state
    • IVC
      • ‘collapse index’
    • Cardiac
      • Small chamber size ‘small heart’
      • Aggressive wall motion ‘hyperdynamic’
  • To identify possible causes
    • AAA
    • Free fluid (haemoperitoneum)

emergencyultrasound.org.uk

tamponade
Tamponade

Aims of ACES scan to:-

  • Identify pericardial effusion
  • Collapse RA/RV during diastole = tamponade

emergencyultrasound.org.uk

slide17
PE

ACES scan aims to identify:-

  • RV dilatation
      • RV hypokinesis
      • Paradoxical septal motion
  • IVC distension
  • (Peripheral views for DVT)

emergencyultrasound.org.uk

cardiogenic
Cardiogenic

ACES scan aims to identify gross abnormalities of

cardiac:-

  • Size
      • Normal
      • Small
      • Dilated
  • Motion
      • Normal
      • Hyperdynamic
      • Hypodynamic

Hypodynamic myocardium = cardiogenic

emergencyultrasound.org.uk

sepsis
Sepsis

ACES scan aims to identify:-

  • Hyperdynamic left ventricular function
  • 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

emergencyultrasound.org.uk

aces scan 6 windows
ACES scan - 6 windows
  • Cardiac
  • IVC
  • Aorta
  • RUQ
  • LUQ
  • Pelvis

emergencyultrasound.org.uk

ivc and collapse index
IVC and collapse index
  • Relationship between IVC pressure and RA pressure
  • Identify IVC
  • Measure in inspiration and expiration
  • M mode
  • Calculate ‘collapse index’

emergencyultrasound.org.uk

ivc and collapse index22
IVC and collapse index

emergencyultrasound.org.uk

collapse index
Collapse Index
  • Inspiration – IVC collapses slightly
  • Expiration – IVC maximal diameter

emergencyultrasound.org.uk

collapse index ci
Collapse Index (CI)

Max diameter – Min diameter

CI = x 100%

Max diameter

Maximum diameter - expiration

Minimum diameter - inspiration

emergencyultrasound.org.uk

collapse index25
Collapse Index
  • CI > 50% = RA pressure < 10mmHg
  • CI < 50% = RA pressure > 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

emergencyultrasound.org.uk

aces scan subcostal
ACES scan - subcostal
  • Pericardial effusion
  • Gross assessment of cardiac wall motion
      • Normal
      • Hypodynamic
      • Hyperdynamic
  • Gross assessment of cardiac chamber size

emergencyultrasound.org.uk

aces scan additional views
ACES scan – additional views
  • Thoracic views – parasternal, apical
  • Augment subcostal view
  • (Peripheral views – DVT)

emergencyultrasound.org.uk

summary aces scan
Summary ACES scan

emergencyultrasound.org.uk

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