Ultrasound In Management

of Shock In Children
Chor Yek Kee
Sarawak General Hospital
 Shock
Definition of shock
Acute and complex state of circulatory dysfunction that
result in failure to deliver sufficient amount of oxygen and other
nutrients to meet tissue metabolic demand
 Categories Of Shock
1. Hypovolemic
2. Cardiogenic
3. Obstructive
4. Distributive
5. Septic
6. Endocrine
 The Late Dr Max Harry Weil
The father of Critical Care Medicine
• In 1972,Weil and Shubin described
• shock as a pathophysiological response,
• proposed a classification system that we are
using today.
•Windows into body
• Altered mental status
• Orthostatic blood pressure
• Capillary refill time
• Subungual perfusion measurement
• Cold limbs
• Lung crackles
• Narrow pulse pressure
The New Window Into Body
 Important Message Before We Start
• Ultrasound cannot take the place of good history and
physical nor essential lab and diagnostic studies

• A careful, complete physical examination is an

essential early step in evaluating any patient
presenting with shock, as is an assessment of the acid-
base status and an electrocardiogram.
 Important Message Before We Start
• Once the initial history and physical has been
performed, focused bedside ultrasound can be
performed rapidly, targeted at specific clinical
question.
• Shock categories frequently overlap, POC ultrasound
can hinder diagnosis if there is premature closure
based on a single abnormal finding in a limited
examination
 Types of shock
1. Hypovolemic
2. Cardiogenic TANK
3. Obstructive
PUMP
4. Distributive
5. Septic
PIPE
6. Endocrine
Emergency Medicine Clinics of North America

The RUSH Exam:

Rapid Ultrasound in SHock in
the Evaluation of the
Critically lll
February 2010, Pages 29–56
High Risk Emergencies
 RUSH
Pump-Tank-Pipe Approach

Pump Tank Pipe

 Sequencing the RUSH
• This entire exam can be completed in less than 2 minutes using
readily available portable machines.
• We go in the order of the HI-MAP acronym.
• H - Heart
•I - IVC
• M - Morrison’s pouch/FAST
• A - Aorta. IJC
• P - Pneumothorax, Penumonia, Pleural effusion,
Pulmonary edema
HI-MAP Sequencing for RUSH
H - 1,2
I - 3,4
10
8

9 10 M - 5,6,7
A -8
5 4
6 10. Aortic P
arch and IJC- 9,10

7
 RUSH Ultimate Aim
•Pump Diagnosis
• Fluid
• Inotropes
•Tank And
Treatment • Antibiotic
•
•Pipe strategies
•
Prostin
Procedure
Drain
Operation
HI-MAP Sequencing for RUSH
H - 1,2
I - 3,4
10
8

9 10 M - 5,6,7
A -8
5 4
6 10. Aortic P
arch and IJC- 9,10

7
 Heart
1. Pericardial Space
2. Myocardium Wall Thickness
3. Cardiac Contractility
4. Cardiac Rhythm
5. Chamber Size
6. Valves
7. Coronary artery
Pericardial Effusion
Hypertrophied myocardium
Cardiac Contractility
Cardiac Contractility
Cardiac arrhythmia
Chamber size
Chamber size
Chamber size
Valves
Valves
Coronary Arteries
 ALCAPA
Anomalous Left Coronary Artery From Pulmonary Artery
HI-MAP Sequencing for RUSH
H - 1,2
I - 3,4
10
8

9 10 M - 5,6,7
A -8
5 4
6 10. Aortic P
arch and IJC- 9,10

7
 Inferior Vena Cava
Spontaneous Spontaneous Ventilated
inspiration forced exhalation Inspiration
 Inferior Vena Cava
Collapsible Non- collapsible
Inferior Vena Cava
Inferior Vena Cava
SPONTANEOUS BREATHING
Collapse index > 50%
- likely hypovolaemia
-CVP < 10

Collpase index < 20%

-Unlikely fluid responsive

Intubated
Distention Index >20 % in ventilated child
- maybe fluid responsive
Inferior Vena Cava
Inferior Vena Cava
HI-MAP Sequencing for RUSH
H - 1,2
I - 3,4
10
8

9 10 M - 5,6,7
A -8
5 4
6 10. Aortic P
arch and IJC- 9,10

7
Morrison Pouch/FAST
Traumatic
Morrison Pouch/FAST
Traumatic
Morrison Pouch/FAST
Non traumatic
Morrison Pouch/FAST
non-traumatic
HI-MAP Sequencing for RUSH
H - 1,2
I - 3,4
10
8

9 10 M - 5,6,7
A -8
5 4
6 10. Aortic P
arch and IJC- 9,10

7
Internal Jugular Vein
Internal Jugular Vein
 Aortic Arch
• Obstructive shock
• Coarctation of Aorta
• Interrupted Aortic Arch
Normal Aortic Arch
Coarctation of Aorta
Coarctation of Aorta
HI-MAP Sequencing for RUSH
H - 1,2
I - 3,4
10
8

9 10 M - 5,6,7
A -8
5 4
6 10. Aortic P
arch and IJC- 9,10

7
Pulmonary edema
Pulmonary Edema
Normal Lung Pneumothorax
 Lung Point

ULTRASOUND OF
PNEUMOTHORAX Absence of
sliding sign

Lung Pneumothorax

A line
 Pneumonia
Subpleural consolidation Shred Sign Hepatization/ total
lung consolidation
 Pneumonia
Air bronchogram in the consolidated lung
Large Pleural effusion
Jelly Fish sign :
Massive Pleural Effusion
Exudative fluid with fibrin
Empyema
Case 1
 History
• 3 years old boy, sitting between parents in a
motorbike
• Knocked down by lost controlled car
• Child was threw out 300m away from the scene
• No eye witness
• Resuscitated at district hospital
• Arrive to PICU after 3 hours journey
HI-MAP Sequencing for RUSH
H - 1,2
I - 3,4
10
8

9 10 M - 5,6,7
A -8
5 4
6 10. Aortic P
arch and IJC- 9,10

7
Concusion?
Thanks