Post on 15-Jan-2017
Insuffisance cardiaque aïgue aux urgences:
je dois aller plus loin avec l’échographie thoracique
David Sapir SAMU 91
JNUC dec 2015
Conflit D’ intérêt Lilly daiichy-sankyo Astra-zeneca Boerhinger Sanofi Shire
Pourquoi faire de l’echo aux urgences pour ICA ?
-‐ Diag difficile -‐ Pronos<c sévère -‐ Incer<tude diag ds 50% -‐ Importante d’une pec rapide
Echo et médecine d’urgence • OBJECTIF : répondre à une ques<on précise dans un contexte clinique
spécifique => echo ciblée
ACEP Emergency Ultrasound Guidelines 2008.
En France, Plus de débat !
ETAT des LIEUX • Echo Essonne: 17% des SAU, 50% des SMUR • Forma<on médecin : 37% SAU, 73% SMUR (forma<on privée 62%)
Hansel, SFMU 2012 Herkelmann, thèse 2013
• Disponibilité écho en France 52% des SAU, 9% des SMUR • => 31 % en 2013 (vardon afar 2014) • Forma<on privée 71%
Formation de 12h (theorie + pratique) ; etude sur1 an, 100 patients inclus par 9 med
COURBE D’APPRENTISSAGE ETT
6 internes MU, formation de 2 jours (ETT « de base », epanchement intra-abdo et echo pulmonaire, AAA)
Concordance diagnostique entre internes et opérateur expérimenté
ETT =Bonne concordance après 30 examens supervisés échographie générale = après 20 examens supervisés ,
echographie pulm =apres 20 à 30 examens supervisés
C. Carrié, SRLF 2014.
ECHOGRAPHIE d’ URGENCES Formation locale tous les 6 mois
Résultats :
• 114 patients inclus sur 8 mois par 16 médecins: 10 médecins ayant reçu la formation initiale (60% des inclusions) et 6 médecins d’un niveau avancé (Diplôme spécifique, au moins 3 ans d’expérience).
• Le motif de départ est le plus souvent une douleur thoracique (54%), une dyspnée (15%), ou un traumatisme sévère (10%).
• ECHO THORAX = 2/3 DES ECHOS • La durée moyenne d’une échoscopie est de 5,7
minutes ; l’expérience du médecin n’influe pas sur cette durée.
• Un changement d’orientation intervient dans 17% (IC95% : 10,6-25,4%) des cas, avec une tendance en faveur des médecins les plus expérimentés (23% versus 13%, non significatif).
• Par ailleurs, nous observons 21% de changement de diagnostic post échoscopie, et 15% de changement de thérapeutique post-échoscopie.
Echoscopie ultra-‐portable en SMUR (SMURSCOPE): impact sur la prise en charge pré-‐hospitalière et
l’orientaBon du paBent. R052
choc = ECHO INCONTOURNABLE Nombreux protocoles échographiques…
Rush protocole
o Rapid Ultrasound for Shock and Hypotension
o Recherche d’informa<ons échographiques orientant vers une é<ologie précise (et a défaut d’exclure certains diagnos<cs differen<els)
o Permet une prise en charge ini<ale en urgence ciblée plus spécifique
o Durée 2 min
RUSH protocol
o The PUMP
o The TANK
o The PIPES
The pump
o Défaillance cardiaque
o Recherche: • Épanchement péricardique • Dysfonc<on ventriculaire gauche • Dysfonc<on ventriculaire droit
The tank
o Evalua<on des compar<ments
o Recherche: • VCI: augmentée/normale/appla< • Saignement abdominal: fast echo • Pneumothorax: point poumon
The pipe
o Évalua<on des vaisseaux
o Recherche • Aorte: Anévrysme /dissec<on • TVP: échographie 4 points
Etat clinique grave =
Image échographique caricaturale le plus
souvent (90%) Cholley, ICM, 2006 Mayo, Chest, 2009
Hojberg holm, Anest Anal, 2012
Patient plus complexe = examen complet spécialisé
Abdomen: Morisson
Efficacité
Ghane MR et al.
3Trauma Mon. 2015;20(1):e20095
The Kappa index for general agreement between shock types was defined using the RUSH protocol and final diag-nosis was 0.71 (P = 0.000) for all patients. This index was 0.70 (P = 0.000) when the protocol was performed by the EP and 0.73 (P = 0.000) when performed by the radiolo-gist, reflecting acceptable agreement for this protocol. Table 2 shows the sensitivity, specificity, PPV, NPV and Kappa index of the protocol for determining each indi-vidual type of shock, among all patients with known final diagnoses.4.1. Hypovolemic ShockExcellent sensitivity, good specificity and highest agree-ment with final diagnoses were seen in hypovolemic shock. We had 16 cases finally diagnosed as having hypo-volemic shocks who were all found based on RUSH find-ings (100% sensitivity, and 100% NPV). Five were due to gas-troenteritis, five due to traumatic solid organ injury, two due to diuretic overuse, two with gastrointestinal bleed-ing; one had a ruptured aortic aneurysm and one aortic dissection. We misdiagnosed two other patients as hav-ing hypovolemic shocks according to their sonography findings, yet the final diagnosis of one was determined as mixed and the other one as distributive shock secondary to urosepsis (96.2% specificity and 88.9% PPV). The criteria had the largest agreement with the final diagnosis (92%, P < 0.001) in this group of patients.4.2. Cardiogenic ShockGood sensitivity, specificity and good agreement were seen in cardiogenic shock. We correctly distinguish 18 out of our 20 cardiogenic shock cases, indicating 90% sensitivity. Eleven were due to decompensated heart fail-ure, three had myocardial infarction (MI), one had digi-tal toxicity, and three had atrial fibrillation with a recent onset of rapid ventricular response. The cardiac etiology of the other two patients with heart failure could not be outlined by the initial RUSH exam (97% NPV). Their illness was due to diastolic dysfunction (in context of paroxys-mal supraventricular tachycardia (PSVT)) and their ejec-tion fraction was assumed good, and thus their shock was labeled as “not-defined” based on sonography findings.
We also had two patients who were diagnosed as having cardiogenic shocks, one of them proved to have multiple causes and the other died before definite diagnosis could be made (98% specificity and 94.7% PPV). Agreement of sonography findings with final diagnosis was 89% (P < 0.001) for this shock type. 4.3. Obstructive ShockNotable reliability indices and agreement were seen in obstructive shock. Among 11 patients with obstruc-tive shocks, we only missed one case, which was due to traumatic rupture of the left hemidiaphragm (90.9% sensitivity and 98.3% NPV). By using the RUSH proto-col, our examiners successfully diagnosed two patients with cardiac tamponade, two with extensive acute pulmonary thromboembolism, three with right heart failure related to secondary pulmonary hypertension (in the context of chronic pulmonary thromboembolic disease in two cases, and extensive pulmonary paren-chymal disease in the other) two of three with pneu-mothorax. Pneumothorax in one patient could not be found with RUSH, however, the patient was correctly found to have an obstructive type of shock by sonogra-phy findings. One patient was labeled as having an ob-structive shock but was found to have a mixed etiology (98.2% specificity and 90.9% PPV). Agreement of sonog-raphy findings with final diagnosis was 89% (P < 0.001) for this type of shock.4.4. Distributive ShockGood agreement, excellent specificity, but low sensi-tivity was seen in distributive shock. We found eight pa-tients with distributive shocks with the early RUSH exam. Eleven patients had final diagnosis of distributive shocks; seven had sepsis (five with pneumonia, and one with cholangitis, iliopsoas abscess, tuberculosis and urinary tract infection) and two were due to neurogenic mecha-nisms. Two patients were miscategorized as hypovolemic and mixed etiology shock, and one could not be defined based on sonography findings (72.7% sensitivity and 95.1% NPV). The protocol demonstrated good agreement with final diagnosis in these patients (0.81, P < 0.001).
Table 2. Reliability Indices and Kappa Agreement of the Rapid Ultrasound in Shock Exam for Each Individual Shock Subtype a,bShock Type Based on Final Diagnosis
Hypovolemic (n = 16) Cardiogenic (n = 20) Obstructive (n = 11) Distributive (n = 11) Mixed (n = 11)Sensitivity 100% 90% 90.9% 72.7% 63.6%Specificity 96.2% 98% 98.2% 100%% 98.2%PPV c 88.9% 94.7% 90.9% 100% 87.5%NPV 100% 97% 98.3% 95.1% 93.3%Kappa (P Value) 0.92 (0.000) 0.89 (0.000) 0.89 (0.000) 0.81 (0.000) 0.70 (0.000)a Data are presented as percentages.b For these analysis eight patients with “not defined” final diagnoses were excluded.c Abbreviation: PPV, positive predictive value of RUSH criteria to determine each type of shock; NPV, negative predictive value of RUSH criteria to determine each shock type; Kappa, index of agreement between diagnosis of shock type based on RUSH criteria and final diagnosis.
Accuracy of Rapid Ultra sound in Shock (RUSH) Exam for Diagnosis of Shock in CriBcally Ill PaBents Mohammad Reza Ghane ; Mohammad Hadi Gharib et al. Trauma Mon. 2015;20
ACR
Les données de la littérature étude clinique randomisée=0
étude clinique = 1
Nos référentiels
Nos référentiels
BNP -‐ NTproBNP • Plus le diagnos<c et le TT de l ICA sont adequats et precoces ,
meilleur est le pronos<c (ray , cc 2006) • Memes perf diag BNP ou NTproBNP ; • Réponse a un stress parietal ou e<rement des myocytes
ventriculaires • Marqueur Pronos<c +++, suivi (Januzzi 2005, Maisel 2001) • ETIOS modifica<on BNP :
• ICA • SDRA, HTAP, Pneumopathie • IVD (EP, decompensa<on BPCO) • TACFA • Anémie • SCA • Pers agées • IR avancée • Choc sep<que • IC Chronique • Obesité ↘
McCullough 2003 De Lemos 2001 Ten Wolde 2003 Mueller 2005 Chenevier 2008 Doust 2004 Schwam 2004
ZONES GRISES (15 a 20% des pa<ents) variables
• 2000 pa<ents • 4 RCT • Tendance a diminuer hosp Diminuer hosp USI Duree hospi
129 ICA – 89 BPCO/asthme Cut off NTproBNO = 1000pg/ml
Ligne A Ligne B
320 pa<ents rando entre méthode diag standart => 63% de diag presumé correct à H4 méthode diag standart + echo au lit pulm, cœur , veine => 88% de diag presumé
Diag exact présumé à 4h = augmenta<on rela<ve de 38 %
Cout biologie embarquée ex de l’i stat
Appareil complet = 9000 euro Cartouche (bnp ou tropo) 25 à 35 euro
Delai 10 à 20 ‘ min par cartouche Temperature 16 – 25°
Vs
L echo pour ICA mais pas que …. Diag posi<f Diag e<o Diag differen<els évolu<on
BLUE PROTOCOLE
Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Lichtenstein DA, Mezière GA. Chest. 2008 Jul;134(1):117-‐25
BLUE PROTOCOLE
Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Lichtenstein DA, Mezière GA. Chest. 2008 Jul;134(1):117-‐25
Detresse respi et DT chez BPCO sévère
exa : diminu<on MV +++ bilaterale
et sibillants
Détresse respi
crépitants Gche >>> droite toux
febricule
Sommet droite / Base droite
Base gauche
l écho thoracique c’est • résultat immediat • Exa répétés • Non invasif • Informatif++++ • Complète exa
clinique : echo ciblée
• Rech de caricature • Incontournable si
choc .
Le plus dur si Appareil dispo …. C’est de l’allumer