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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

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The aces scan l.jpg

The ACES scan

Ultrasound in hypotension

Richard Kendall

Paul Atkinson

emergencyultrasound.org.uk


The aces scan2 l.jpg

TheACES scan

  • Abdominal

    (and)

  • Cardiac

  • Evaluation

    (with sonography in)

  • Shock

emergencyultrasound.org.uk


The aces scan3 l.jpg

The ACES scan

  • Extension of more established emergency medicine uses of ultrasound

  • Abdominal component

  • Cardiac component

  • (Peripheral component)

emergencyultrasound.org.uk


Case 1 l.jpg

Case 1

  • ‘Red call’

  • Elderly female – collapsed and absent radial pulse

  • Arrives – peri-arrest

  • Groaning

  • Initial resuscitation

  • ACES scan

emergencyultrasound.org.uk


Case 15 l.jpg

Case 1

  • Huge AAA, tender

  • Terminal care instituted

emergencyultrasound.org.uk


Case 2 l.jpg

Case 2

  • ‘Red call’

  • 62 year old man

  • Hypotension, epigastric pain

  • Unwell ?AAA

  • 10 minutes

emergencyultrasound.org.uk


Case 27 l.jpg

Case 2

  • BP 74/54, Pulse 110, clammy

  • Initial resuscitation underway

  • ACES scan

emergencyultrasound.org.uk


Abdomen l.jpg

No AAA

Abdomen

emergencyultrasound.org.uk


Abdomen9 l.jpg

No free fluid

Abdomen

emergencyultrasound.org.uk


Abdomen ivc l.jpg

Abdomen - IVC

  • Slight collapse on inspiration

emergencyultrasound.org.uk


Cardiac subcostal l.jpg

Cardiac - subcostal

  • No pericardial effusion

  • Hyperdynamic

  • Not small

  • RV not dilated

emergencyultrasound.org.uk


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CXR

  • Fluid challenge

  • IV antibiotics

  • IJ line

    (us control)

  • ICU

emergencyultrasound.org.uk


Aces scan l.jpg

ACES scan

  • Aim is to help identify the likely cause of hypotension

emergencyultrasound.org.uk


Causes of hypotension l.jpg

Causes of Hypotension

  • Hypovolaemia

  • Obstructive (tamponade)

  • Obstructive (PE)

  • Cardiogenic

  • Distributive (septic)

emergencyultrasound.org.uk


Hypovolaemia l.jpg

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 l.jpg

Tamponade

Aims of ACES scan to:-

  • Identify pericardial effusion

  • Collapse RA/RV during diastole = tamponade

emergencyultrasound.org.uk


Slide17 l.jpg

PE

ACES scan aims to identify:-

  • RV dilatation

    • RV hypokinesis

    • Paradoxical septal motion

  • IVC distension

  • (Peripheral views for DVT)

  • emergencyultrasound.org.uk


    Cardiogenic l.jpg

    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 l.jpg

    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 l.jpg

    ACES scan - 6 windows

    • Cardiac

    • IVC

    • Aorta

    • RUQ

    • LUQ

    • Pelvis

    emergencyultrasound.org.uk


    Ivc and collapse index l.jpg

    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 l.jpg

    IVC and collapse index

    emergencyultrasound.org.uk


    Collapse index l.jpg

    Collapse Index

    • Inspiration – IVC collapses slightly

    • Expiration – IVC maximal diameter

    emergencyultrasound.org.uk


    Collapse index ci l.jpg

    Collapse Index (CI)

    Max diameter – Min diameter

    CI =x 100%

    Max diameter

    Maximum diameter - expiration

    Minimum diameter - inspiration

    emergencyultrasound.org.uk


    Collapse index25 l.jpg

    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 l.jpg

    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 l.jpg

    ACES scan – additional views

    • Thoracic views – parasternal, apical

    • Augment subcostal view

    • (Peripheral views – DVT)

    emergencyultrasound.org.uk


    Summary aces scan l.jpg

    Summary ACES scan

    emergencyultrasound.org.uk


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