Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review

Abstract

Rapid and accurate diagnosis and treatment are paramount in the management of the critically ill. Critical care ultrasound has been widely used as an adjunct to standard clinical examination, an invaluable extension of physical examination to guide clinical decision-making at bedside. Recently, there is growing interest in the use of multi-organ point-of-care ultrasound (MOPOCUS) for the management of the critically ill, especially in the early phase of resuscitation. This article will review the role and utility of symptom-based and sign-oriented MOPOCUS in patients with undifferentiated respiratory difficulty, chest pain, or shock and how it can be performed in a timely, effective, and efficient manner.

Keywords: Chest pain; Multi-organ point-of-care ultrasound; Respiratory difficulty; Shock.

Fig. 1

Sequence of MOPOCUS scanning

Fig. 2

The algorithm (Figs. 2, 7, 8, 12, 14, 16, and 19) begins at the top with the primary ultrasound finding or application (extra bold tab) and primary clinical presentation (rectangle) and proceeds downwards. The specific MOPOCUS findings are indicated by the bold tab, while the tab itself represents the diagnosis. The double-lined rectangular frame suggests further ultrasound assessment or clinical intervention. The sequence of assessment and interpretation is guided by the black line behind these icons

Fig. 3

Algorithm for normal lung pattern in lung ultrasound. COPD chronic obstructive lung disease, US ultrasound, PNX pneumothorax, DDx differential diagnosis

Fig. 4

A-lines. A-lines (arrowheads) are horizontal artifacts generated by the repeated reflection of the ultrasound beam between the pleural line and the probe surface

Fig. 5

Lung point. Alternating seashore sign (left) and stratosphere sign (right) on M mode is pathognomonic for pneumothorax

Fig. 6

Pleural effusion. Pleural effusion (asterisk) permits the ultrasound beam to penetrate deeply to reveal the vertebral stripe (arrow). The vertebral stripe will not be visible above the diaphragm if the lung is aerated

Fig. 7

Algorithm for diffuse interstitial pattern in lung ultrasound. IVC inferior vena cava, LV left ventricle, ALI acute lung injury, ARDS acute respiratory distress syndrome

Fig. 8

Algorithm for abnormal non-diffuse interstitial pattern in lung ultrasound. IS interstitial syndrome, PE pulmonary embolism, IVC inferior vena cava, PNX pneumothorax

Fig. 9

B-lines. B-line (arrow) is a bright comet-tail artifact that arises from the pleural line (arrowhead). It will move with lung sliding, if the sliding is present, and extends to the end of the screen without fading

Fig. 10

Lung consolidation. When the lung is consolidated (asterisk), it has a tissue-like appearance. The consolidation also allows penetration of the ultrasound beam, revealing the vertebral stripe (arrow)

Fig. 11

Alveolar consolidation and dynamic air bronchogram. Hypoechoic tissue-like patterned consolidation of the right upper lobe. Bright spots or streaky appearances are air bronchogram (arrow). A dynamic air bronchogram is visualized in the real-time image

Fig. 12

Algorithm for shock assessment. IVC inferior vena cava, RV right ventricle, LV left ventricle

Fig. 13

Inferior vena cava (IVC). IVC (arrow) draining into the right atrium (asterisk)

Fig. 14

Cardiac ultrasound in respiratory difficulty. PE pulmonary embolism, LV left ventricle, ARDS acute respiratory distress syndrome, PF pulmonary fibrosis, IPn interstitial pneumonia, AR aortic regurgitation, MR mitral regurgitation, Decom. decompensated, MVD mitral valve disease, AVD aortic valve disease, AMI acute myocardial infarction, HF heart failure

Fig. 15

Left ventricular hypertrophy. Left ventricular hypertrophy involving both septal and lateral walls (2.14 cm). The left atrial appeared enlarged

Fig. 16

Cardiac ultrasound in chest pain. RWMA regional wall motion abnormality, Pn pneumonia, PE pulmonary embolism, PNX pneumothorax, AMI acute myocardial infarction

Fig. 17

Thoracic aortic dissection. A moving intimal flap (arrow) in a proximal thoracic is visualized in the real-time image

Fig. 18

Abdominal aortic dissection. An intimal flap (arrow) dissecting into the lumen of the abdominal aorta. The arrowhead points to the vertebral stripe, on which the aorta lies

Fig. 19

Cardiac ultrasound in shock. IVC inferior vena cava, LV left ventricle, RV right ventricle, LVOT left ventricular outflow tract, PE pulmonary embolism, AMI acute myocardial infarction, HCMP hypertrophic cardiomyopathy, MR mitral regurgitation, AR aortic regurgitation, Decomp. decompensated, MS mitral stenosis, AS aortic stenosis

Fig. 20

Cardiac tamponade. Right-sided heart chambers collapsed (arrow), due to increased intrapericardial pressure from a large pericardial effusion (asterisk)

Fig. 21

Cardiac tamponade physiology. (Left) Cardiac tamponade physiology, demonstrating reduced and aggravated variation of mitral valve inflow velocity. (Right) Post-pericardiocentesis: significant improvement in mitral valve inflow velocity

Fig. 22

D-shaped left ventricle. The interventricular septum is normally round and bulges into the right ventricle (RV) throughout the cardiac cycle. Increased RV pressure causes the septum to be deformed to assume a “D”-shaped left ventricle (arrow)

Fig. 23

Pulmonary embolism, severe. Right ventricular enlargement (more than 0.9 of left ventricular size) is demonstrated (white asterisk). The RV free wall does not appear thickened, indicating an acute RV failure

Fig. 24

Apical ballooning syndrome. Severe hypokinesia of mid-ventricle sparing the basal segments (arrow). This is better appreciated during real-time scanning. Courtesy of Dr. Seong-Beom Oh

Fig. 25

Flailed mitral valve. Flailed posterior mitral leaflet (arrow). Note the presence of a small pericardial effusion (arrowhead) and larger left pleural effusion (asterisk)