title: A bedside clinical and ultrasound-based approach to hemodynamic instability - Part II: bedside ultrasound in hemodynamic shock: continuing professional development.
abstract: Shock is defined as a situation where oxygen transport and delivery is inadequate to meet oxygen demand. The patient in shock is evaluated through medical history, physical examination, and careful observation of the hemodynamic and respiratory monitors. The patient is initially managed with basic resuscitation measures, however bedside ultrasound should be performed if hemodynamic instability persists. We propose to use ultrasound of the inferior vena cava (IVC), and the concept of venous return, as the initial step in order to identify the mechanism of shock. Doppler examination of the hepatic venous flow can also be added. Further ultrasound examination of the patient's heart, thorax, and abdomen can then be performed in order to determine the etiology of shock. In patients with reduced mean systemic venous pressure, an examination of the patient's thoracic and abdominal cavities to detect free fluid, pneumonia, or empyema can be considered. In patients with increased right atrial pressure, transthoracic echocardiography will allow identification of left or right ventricular dysfunction. Finally, in the presence of increased resistance to venous return, thoracic examination for pneumothorax or cardiac tamponade and abdominal examination for signs of abdominal compartment syndrome or IVC occlusion can be considered. Subsequent treatment can then be tailored to the etiology of shock. Elements of bedside ultrasound examination are currently taught in many anesthesia training programs.
  
  
  OBJECTIVE
  To develop an approach to the patient in shock that incorporates bedside ultrasound examination.
authors.affiliation: Department of Anesthesiology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Annette
authors.initials: A
authors.lastname: Vegas
authors.forename: André
authors.initials: A
authors.lastname: Denault
authors.forename: Colin
authors.initials: C
authors.lastname: Royse
mesh_terms: D004452:Echocardiography / Q000379:methods; D006439:Hemodynamics; D006801:Humans; D019095:Point-of-Care Systems; D012769:Shock / Q000000981:diagnostic imaging* / Q000503:physiopathology; D018608:Ultrasonography, Doppler / Q000379:methods*; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis; D018497:Ventricular Dysfunction, Right / Q000175:diagnosis