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