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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Role of echocardiography in the management of shock

Abstract

Hemodynamic instability and inadequate cardiac performance is frequently found in critically ill patients. Transthoracic and transesophageal (in the case of inadequate visibility) echocardiography is increasingly used for non-invasive hemodynamic assessment and monitoring in the ICU setting. Using echocardiography, it is possible to assess preload, fluid responsiveness, systolic and diastolic cardiac function, and calculate cardiac output, intravascular and intra-cardiac pressures. It is the golden standard in the initial hemodynamic assessment and should be used as complementary tool in invasively monitored patients in the case of new circulatory or respiratory failure. Echocardiography is indispensable in the management of shock patients and is extremely powerful diagnostic role for the cardiac abnormalities (pericardial effusion and tamponade, acute cor pulmonale and acute or chronic valvular disorders) as a cause for hemodynamic instability. It is the most important and suitable method for assessment of right ventricular function, for diagnosis of septic cardiomyopathy and cardiac causes of weaning failure. Because of these advantages it should be routinely used by intensivists for hemodynamic assessment and monitoring and should be continuously available in the intensive care unit. The most important limitations of echocardiography are its inability to estimate adequacy of cardiac output and its intermittent nature. Therefore it should be used in rational combination with other complementary and continuous monitoring methods.

Key words: echocardiography, circulatory shock, critically ill patients

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Rapid Sequence Intubation in the Pre-Hospital Setting – Difference Between Trauma and Nontrauma Patients

Abstract

Aim. To determine, in a prospective observational study, whether there are differences in the practice of rapid sequence intubation (RSI) and to ascertain the characteristics between trauma and non-trauma patients that were intubated in a pre-hospital setting.
Methods. Included were patients (18 years and over) who were not in cardiac arrest and who underwent RSI and were transported to hospital. From January 2000 to December 2006 we intubated 636 patients in cardiac arrest, 159 critically ill non-trauma patients and 142 trauma patients. Placement of an endotracheal tube was confirmed by capnography. We compared medical and trauma groups of intubated patients. We used the two-independent sample t-test, Chi-square test and Wilcoxon-Mann Whitney test for statistical analysis.
Results. Statistical differences between groups (medical vs. trauma): initial main arterial pressure (104.9 +/- 34.6 vs. 90.7 +/- 24.8; p=0.01), blood glucose levels (9.2 +/- 3.5 vs. 5.9 +/- 1.9; p=0.011), administration of colloids (13,1 % vs. 70,2; p=0.003) and Hyperhaes (2.5 % vs.17.6 %; p=0.001), male gender (62.3 vs 81.6; p=0.014), rate of RSI (71.1 % vs. 96.4 %; p<0.001), initial GCS distribution 3-4/5-8/9-15 (30.9 % /61.6 % /7.5 % vs 11.7 % /60,2 % /28,1 %; p<0.001), initial pet CO2 (49,5 +/- 8,4 mmHg vs. 32,8 +/- 5.4 mmHg; p=0.007), APACHE II first day of hospitalization (25,9 +/- 4.9 vs. 20,8 +/- 3.6; p=0.002) and hospital mortality (78/159 (49.1 %) vs. 44/142 (30.1 %); p=0.023). We also analyzed the number of intubation attempts, intubation success rate, perceived difficulty of intubation and side effects with complications. The hospital survival analysis showed that survivors are younger (54.2 +/- 19.9 vs. 62.3 +/-18.8; p=0.019), have a higher rate of RSI (175/179(97.7 %) vs. 75/122(61.6 %); p=0.002) and have a better (lower) APACHE II score (19.9 +/-3.6 vs.28.3 +/- 4.6; p=0.002). We found the highest mortality rate in the subgroup of patients with non-traumatic intracranial hemorrhage (58.8 %, 60/102).
Conclusion. In non-trauma, critically ill patients we found a lower rate of RSI, more patients with an initial GCS of 3-4, higher APACHE II first day, higher initial pet CO2 and higher hospital mortality than in trauma patients.

 

Keywords: rapid sequence intubation, pre-hospital setting, injured patients, critically ill patients, prognosis

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