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| Outlines | Rationale | Tale |
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1.
Problems emerged? | The signs of the deterioration should be classified into two aspects: acute circulatory compromise and acute respiratory compromise | Heart rate increase/drop, hypotension, oliguria, acidosis, increased requirement of vasopressor or other symptoms would be defined as acute circulatory compromise |
| Acute respiratory distress, decrease in oxygenation, increased dependence of ventilator, patient-ventilator asynchrony, or other symptoms would be defined as acute respiratory compromise |
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2.
Information clear? | Quickly summarize the patient’s medical history by three aspects | (1)Any dysfunction of heart and lung caused by basic or chronic diseases? |
| (2)The main dysfunction of circulation and respiration when admitted and its progress? |
| (3)The current clinical manifestation and the lab variables of the patient’s deterioration? |
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3.
Focused exam launched | Focuses exam of the heart by five views, and the contents are listed in the right cell
| (1)Heart glance: fast and global assessment of the heart to identify cases that need immediate life-saving intervention by intensivists or cardiologist, such as tamponade, acute cor pulmonale (pulmonary embolism/tension pneumothorax), ACS, catastrophic valve pathology (AIE/valve failure on chronic valve diseases), and aortic dissection. (2) IVC exam: static volume status, fluid responsiveness. (3)RV exam: identify the acute right heart dysfunction that may harm the output of left side of the heart or cause a false positive monitoring what may mislead the treatment. (4)Diastole of left heart: assesses PAOP increase that could alert the hydrostatic pulmonary edema and the risk to fluid initiation. (5) Systole of left heart: use eyeballing to classify the contraction into 3 categories: hyperkinesis, normal, and abnormal, then identify the abnormality as disseminated or regional wall motion abnormalities, and categorize the former as mild hypokinesis, moderate hypokinesis, and severe hypokinesis. (6) Afterload: deduce the afterload with the above indexes or calculate with MAP and SV accurately |
| Divide the chest wall into 12 exam regions, ultrasonic pattern of each region should be integrated to conclude the overall profile of lung pathology | Identify each region as the following patterns: A pattern-lines associated or not with lung sliding; B pattern: three or more isolate B lines within a scan view; C pattern: consolidation or atelectasis; PE: intrapleura anechoic hypoechoic collection zone. Each pattern should include detailed information. A pattern would be detailed for lung sliding, lung pulse, and lung point; B pattern would be detailed for regularly spaced or irregularly spaced, normal or abnormal pleura; C pattern would be detailed for the morphology, regular or irregular margins, static or dynamic bronchograms; PE would be detailed for strength of the echo, separate or not |
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4.
Pathophysiologic changes reported | The results of the focused ultrasound exam were integrated to conclude the pathophysiologic changes | The supportive treatment would be the basis of the pathophysiologic changes |
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5.
Etiology explored | Diagnosis the etiology by integrating step two and step four; search for the source of infection, according the clues extracted from the focused ultrasound exam; additional ultrasound exams or other tests should applied if needed | (1) Some of the ultrasonic clues that may contribute to guiding the diagnosis:
-Acute cor pulmonale may indicate pulmonary embolism, unreasonable ventilation setting, or severe mismatch of the ventilation and flow representing ARDS; acute increase in PAOP derives from decrease in systolic function, left side valve insufficiency, hypervolemia, or decreased myocardium compliance; diffuse SIS may indicate hypervolemic pulmonary edema, cardiogenic pulmonary edema, leakage pulmonary edema, acute pneumonitis, pulmonary alveolar proteinosis, and chronic pulmonary fibrosis; consolidation with shred sign in lung ultrasound may indicate pneumonia; hypoechoic yet heterogeneous collections at plural cavity indicate hemothorax or pyothorax; echogenic dots in physiology cavity indicate infection, etc.
(2) Additional ultrasonography may be LVOT-VTI, FAST, airway, diaphragm, etc.
(3) Other examinations include blood biochemical examination, CT, PICCO, etc. |
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6.
Action | Support the circulation and respiration sticking to step four | Carry out supportive and other relevant treatments for the circulation and respiration guided by the findings of the pathophysiologic changes in Step four |
| Treat the etiologies according step five | Carry out the therapy of the etiology (antibiotic, drainage of infection source, etc.) guided by the results of Step five |
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7.
Recheck to adjust | Repeat focused ultrasound and other test to assess the response to treatment, adjust the treatment if needed, and confirm or correct the final diagnosis | Repeat ultrasonography in a case-by-case determined time frame to see whether the indexes get better or not
Recheck the clinical information of the patient (vital signs, uop, lactate, ABG, etc.)
Follow up with the patient and the clinical data, order further test or treatment if needed, and summarize the whole care process to achieve the final diagnosis |
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