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Echocardiographic Approach to Shock

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Echocardiographic Approach to Shock Review Article Page 1 of 6 Echocardiographic approach to shock Daniel De Backer, Simone Giglioli Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium Contributions: (I) Conception and design: None; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Daniel De Backer, MD, PhD. Department of Intensive Care, CHIREC Hospitals, Boulevard du Triomphe 201, B-1160 Brussels, Belgium, Email: [email protected]. Abstract: Echocardiography can be used to evaluate the full hemodynamic pattern of patients with shock. Accordingly, echocardiography can rapidly identify the type of shock, helping to guide therapeutic interventions aiming at treat its cause. But echocardiography also provides important information on preload responsiveness, right and left filling pressures, function of the left and right ventricle (RV). Thank to this comprehensive hemodynamic evaluation, echocardiography is nowadays the preferred hemodynamic tool to initially assess a patient with shock, and is thus recommended for this purpose in several consensus documents. Interestingly, echocardiography also allows to perform serial measurements, which is particularly useful to evaluate changes over time as well as the response to therapy. Implementation of echocardiography as a guide to therapy in patients with shock seems to be associated with improved outcomes in observational studies. In this narrative review, we will report on how echocardiography can be used for the management of patients with circulatory failure. Keywords: Echocardiography; shock; ultrasounds; cardiogenic; hypovolemic; distributive; tamponade; cardiac output Received: 27 June 2019; Accepted: 12 July 2019; Published: 12 August 2019. doi: 10.21037/jeccm.2019.07.06 View this article at: http://dx.doi.org/10.21037/jeccm.2019.07.06 Introduction veins) results in a decrease in cardiac preload and hence in cardiac output. Cardiogenic, or failure of pump function, Circulatory shock is a life-threatening condition in which resulting from an impaired contractility, severe valvular the circulation is unable to deliver sufficient oxygen dysfunction or severe arrythmias. Obstructive shock to the tissues in order to meet their basal metabolic results from compression of heart cavities from cardiac requirements, resulting in organ dysfunction (1,2). While tamponade or increase in right ventricular afterload (often clinical signs of shock are very important to detect that the from pulmonary embolism). Finally, distributive shock patient is in shock, these signs do not indicate what is the results from the impairment in vascular tone, associated nature of shock nor whether cardiac output is increased, with severe hypotension, venous dilation (and hence relative normal or decreased (3). Accordingly, the hemodynamic hypovolemia), altered distribution of perfusion between the evaluation is urgently required to identify the type of different organs but also inside each organ (microvascular shock and hence the best therapies to apply (1,2,4,5). impairment). Four different pathophysiological mechanisms can Echocardiography allows to obtain the full hemodynamic result in shock (2,6). Hypovolemia, either absolute (due to evaluation (7) and seems to be associated with improved fluid losses) or relative (due to redistribution of fluids from outcomes in observational cohorts (8). For many reasons, central to peripheral compartments, related to an increase echocardiography is the perfect hemodynamic tool for the in intrathoracic pressures or dilation of large capacitance initial evaluation of the patient in shock. First, it can be © Journal of Emergency and Critical Care Medicine. All rights reserved. J Emerg Crit Care Med 2019;3:35 | http://dx.doi.org/10.21037/jeccm.2019.07.06 Page 2 of 6 Journal of Emergency and Critical Care Medicine, 2019 Table 1 Typical echocardiographic alteration in the various types of shock Echocardiographic Obstructive shock Hypovolemic Cardiogenic Distributive measurement Tamponade Increased RV afterload Cardiac volumes Very small; Small; systolic Dilated RV cavities; Often dilated Variable kissing collapse RA; paradoxical septal ventricles diastolic collapse RV movement Contractility Preserved or Preserved or Impaired RV function Decreased LV or RV function* Variable** increased increased Vena cava size Small size; Dilated Dilated Variable Variable, often respiratory small size; variations respiratory (collapsed) variations if fluid responsive Intravascular Very low; Impaired diastolic Increased PAP; clots Elevated filling pressures (left Variable but pressures respiratory function; respiratory sometimes seen; short and/or right) low in most variations variations PA acceleration time; cases biphasic PA flow Pericardial space Empty Markedly filled; may Empty or minimally Empty or minimally filled Empty or be focal filled minimally filled Other – Check for aortic – Check valves and/or abnormal Check for dissection or cardiac flows (interventricular endocarditis rupture communication) *, left ventricular volume and contractility are often preserved or increased in aortic stenosis; **, left ventricular contractility is impaired in up to 30% of patients on admission, but cardiac output is often preserved. rapidly be available at bedside. Several studies have shown end systolic volume or “kissing ventricles”. The inferior that characterization of the pathophysiological mechanism and superior vena cava sizes are usually small and disclose of shock can be obtained within less than 5 min. Second, significant respiratory variations. Left heart filling pressures the echocardiographic evaluation allows to identify several are low: low mitral E wave, low E/E’ ratio. Aortic velocity patterns that characterize the different types of shock time integral (VTI) and cardiac output are typically low. (Table 1). Third, echocardiography allows to rapidly indicate the potential hemodynamic strategies (fluid responsiveness/ Typical echocardiographic characteristics of impairment of left or right ventricular function/increased obstructive shock due to cardiac tamponade right ventricular afterload……) that can be applied. Fourth, it allows to rapidly evaluate the response to the applied Cardiac tamponade is induced by the increase in therapies. Last, but not least, the information obtained by pericardial pressure. Importantly, the relation between echocardiography is achieved within a timeframe which not pericardial pressure and volume is curvilinear. Also, chronic long enough to insert and derive information from many accumulation of pericardial fluid initially minimally invasive hemodynamic devices. increases pericardial pressure due to the progressive increase in pericardial compliance. Accordingly, diagnosis of cardiac tamponade relies on the detection of hemodynamic signs of Typical echocardiographic characteristics of cardiac tamponade. These include systolic collapse of right hypovolemic shock atrium, diastolic collapse of right ventricle (RV) together Hypovolemic shock is characterized by a decrease in with dilated superior and inferior vena cava. Doppler stressed volume. Accordingly, the cardiac volumes and patterns are also indicative, with respiratory fluctuations in pressures are usually low. This is reflected by small size artic VTI, mitral and tricuspid flows. Finally, Aortic VTI of cardiac cavities, sometimes associated with virtual left and cardiac output are typically low. © Journal of Emergency and Critical Care Medicine. All rights reserved. J Emerg Crit Care Med 2019;3:35 | http://dx.doi.org/10.21037/jeccm.2019.07.06 Journal of Emergency and Critical Care Medicine, 2019 Page 3 of 6 Typical echocardiographic characteristics shock, recognition of cardiogenic shock is based on the of obstructive shock due to elevated right combination of low cardiac output and elevated filling ventricular afterload pressures. The typical pattern includes a low stroke volume associated with elevated left atrial pressure (elevated Increases in RV afterload may lead obstructive shock. mitral E wave and increased E/E’ ratio). Dilation of LV is The RV is sensitive to pressure and volume overload. observed in patients with chronic or subacute impairment Importantly, the RV prolongs its systolic time in face of in LV function (chronic heart failure, myocarditis) but may an increased RV afterload so that the pressure in the RV be absent when an abrupt decrease in LV function is leading exceeds the pressure of the left ventricle (LV) at the end of to cardiogenic shock (such as acute myocardial infarction or systole leading to paradoxical septal movement. Dilation of malignant arrythmias). RV is the cornerstone and its association with paradoxical Cardiogenic shock associated with isolated right heart septal movement defines acute cor pulmonale. Acute failure is characterized by a low cardiac output associated cor pulmonale is usually evaluated by assessing the ratio with elevated right atrial pressure (dilated right atrium and between RV and LV end diastolic volumes in long axis, dilated inferior and superior vena cava) without significant coupled with detection of paradoxical septal movement in pulmonary hypertension. short axis (9,10). The sonographer should evaluate valvular function in RV systolic function can be evaluated by tricuspid order to detect
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