Classification of Shock States:  

Classification of Shock

  • Hypovolenic
  • Cardiogenic
  • Distributive

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Goal Directed Ultrasound in Shock:


  • The Pump
  • The Tank
  • The Pipes

Cardiac Ultrasound:

Pericardial Effusion:

Left Ventricular Dysfunction:

Right Ventricular Enlargement:

Inferior Vena Cava:  Assessment of Volume Responsiveness

IVC in M-Mode

  • Measures an anatomical slice over time
  • Allows easy assessment of change in IVC size with respiration
  • AP diameter changes with respiration
  • Fixed at the diaphragm

Evaluating the Tank: Estimating CVP

IVC Diameter Respiratory Change Estimated CVP
< 1.5 cm Total Collapse <5 cmH20
1.5-2.5 cm >50% Collapse 6-10 cmH20
1.5-2.5 cm <50% Collapse 11-15 cmH20
>2.5 cm <50% Collapse 15-20 cmH20
>2.5 cm No Change >20 cmH20

Obstructive Shock:  Tension Pneumothorax

Tension Pneumothorax

  • Chest Ultrasound quickly identifies PTX
  • More accurate than supine AP chest x-ray
  • To Be continued During E-FAST evaluation

Distributive Shock:  Focused Abdominal Sonography in Trauma 

Aortic Pathology:

Aortic Root Measurement:

The Tank: FAST Exam

  • Focused Assessment with Sonography Trauma
  • Evaluation of intra abdominal Free Fluid
  • Next Lecture…

The Pipes: Aorta

  • Aortic Root Dilation
  • Abdominal Aorta Dilation
  • Abdominal Aorta Dissection

Aortic Root

  • Measure Just Beyond Tips of Valve at End Systole
  • Include Lumen Wall
  • Normal Root Diameter <3cm

Aortic Aneurysm:

Aortic Dissection:

Deep Vein Thrombosis:

Pipes: DVT

  • High Frequency Probe
  • Compression Venography Only
  • Scan From Just Below Inguinal Crease to Popliteal Fossa
  • Waypoints:
    • Common Femoral Vein
    • CFV at confluence with Saphenous Vein
    • Popliteal Vein
  • How Much Pressure?
    • Collapse veins without collapsing artery

Putting it all together:

Ultrasound for Undifferentiated Hypotension


Pericardial Sac for
IVC for Collapsibility Aorta for aneurysm and dissection
LV Size and Contractibility for Cardiogenic Shock Lungs for Pneumothorax, Pulmonary Embolism and Pleural Effusion Femoral and Popliteal Veins for DVT
RV Size for Pulmonary Embolism Abdomen for Free Fluid

USPSTF on screening for abdominal aortic aneurysm

Joseph Esherick, M.D., FAAFP, FHM

July 15, 2014

The USPSTF continues to recommend screening primarily in 65- to 75-year-old men who have ever smoked.

U.S. Preventive Services Task Force (USPSTF)​

Prevalence of abdominal aortic aneurysms (AAAs; defined by an aortic diameter of ≥3.0 cm) in adults older than 50 is as high as 7% in men and 1% in women. In 2005, the USPSTF recommended one-time screening by ultrasonography in 65- to 75-year-old men who had ever smoked (defined as having ever smoked ≥100 cigarettes) and recommended against routine screening in women (NEJM JW Gen Med Feb 18 2005). The USPSTF now has updated its recommendations.

Key Points
—Risk factors: Older age; positive smoking history; having a first-degree relative with AAA; and having a history of vascular aneurysms, coronary artery disease, cerebrovascular disease, hypercholesterolemia, obesity, or hypertension.
—As in 2005, the Task Force continues to recommend:
* One-time screening for AAAs with ultrasound in 65- to 75-year-old men who have ever smoked (Grade: B [recommend]).
* Selective screening for AAAs in 65- to 75-year-old men who have never smoked, if additional risk factors are present (Grade: C [recommend for selected patients]).
* No screening for women who have never smoked (Grade D: [recommend against]).

—The Task Force finds insufficient data to determine the balance of benefits and harms of screening for AAAs in 65- to 75-year-old women who have ever smoked (Grade: I [no recommendation]).
—Screening test: Abdominal duplex ultrasonography has sensitivity and specificity of 97% and 99%, respectively, and is the standard approach for AAA screening.
* Refer patients with large AAAs (≥5.5 cm) for open repair or endovascular intervention.
* For smaller AAAs (3.0–5.4 cm), manage patients conservatively (e.g., with repeat ultrasonography every 3–12 months).
—Screening in men is associated with an absolute risk reduction in AAA-related death of 1.4 per 1000 men screened.

LeFevre ML et al. Screening for abdominal aortic aneurysm: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014 Jun 24; [e-pub ahead of print]. (http://dx.doi.org/10.7326/M14-1204)