Volume 28, Issue 1, March 2025, 101025Author links open overlay panel

Interventional Radiology has evolved to encompass periprocedural and inpatient care of critically ill patients. Acute hypotension and shock can occur in IR patients due to various causes including hemorrhage, sepsis, myocardial infarction, and pulmonary embolism; therefore, the ability to accurately evaluate acutely deteriorating patients must become a part of the IR skillset. Goal-directed sonographic examination of the heart and inferior vena cava provides rapid bedside assessment of anatomic and functional parameters that can be used to determine the etiology underlying a patient's shock. Targets of evaluation include ventricular systolic function/size/thickness, presence of pericardial effusion and tamponade physiology, intravascular volume status, and existence of other structural pathology such as valvular disease and intracardiac masses. Presented is a primer on performing a systematic focused cardiac ultrasound examination for patients experiencing acute hypotension.

Introduction

Although echocardiography has been performed by cardiologists for decades to evaluate cardiac anatomy and function, the recent proliferation of point-of-care ultrasound has allowed practitioners across many patient care settings including the operating room, emergency department, inpatient floor, and periprocedural areas to perform bedside cardiac examinations in real time, particularly for patients experiencing unexplained hemodynamic deterioration. Goal-directed protocols such as Focused Assessed Transthoracic Echocardiography (FATE), Rapid Ultrasound in Shock (RUSH), and Focused Cardiac Ultrasound (FoCUS or FCU) have been developed to allow rapid identification of cardiovascular conditions at the root of a patient's acute hypotension and shock.1

Interventional Radiologists can benefit from becoming proficient with this “modern stethoscope” as we increasingly encounter patients with severe comorbidities or high presenting acuity. For example, a patient may unexpectedly deteriorate in the intraprocedural setting and bedside cardiac ultrasound can be used to identify acute myocardial infarction or guide emergent therapy such as intravenous fluid and vasopressor administration. A patient may present in extremis from hemorrhagic shock, and the consulting IR can use cardiac ultrasound to assess severity of hypovolemia to guide resuscitation efforts and triage appropriate procedural vs operative treatment. Although cardiac ultrasound has not traditionally been included in the IR training curriculum, a strong foundation in radiology should allow IRs to quickly incorporate this skill into their practice. Here, we present a primer on performing a systematic FoCUS exam, including technical considerations, protocolized image and data acquisition, and interpretation of findings, with emphasis on identification of common pathologies that may cause acute hypotension and circulatory shock.

Section snippetsClinical role of FoCUS

Cardiac ultrasound can be used in patients presenting with acute hypotension, arrhythmia, cardiac arrest, chest pain, and syncope to assess for an underlying etiology. Common pathologies that can be diagnosed with FoCUS include ischemic left/right ventricular dysfunction, mechanical postmyocardial infarction (MI) complications, cardiomyopathies (eg, dilated, hypertrophic, and stress variants), myocarditis, valvulopathies, cardiac tamponade, pulmonary embolism, and hypovolemia.2

Of the listed

Probe selection and positioningTypically, a phased-array or “sector” probe is used for cardiac ultrasound. These probes have small footprints and low frequency transduction (∼1-5 MHz) to allow imaging of deep structures through narrow anatomic windows such as intercostal spaces. Two imaging modes are utilized:-

B-mode: basic anatomic evaluation, eg, ventricular size, pericardial effusion

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M-mode: change in position of a single anatomic structure over the course of the cardiac cycle as an indication of contractile ability or

Data acquisition

The FoCUS examination involves systematic evaluation of certain anatomic and physiologic parameters. Targets of evaluation in the setting of acute hypotension include global left ventricular (LV) systolic function, size, and wall thickness; global right ventricular (RV) systolic function, size, and wall thickness; presence of pericardial effusion and tamponade physiology; IVC size and collapsibility as a marker of intravascular volume status; presence of gross valvular abnormalities and outflow

Patterns of disease: clinical application of FoCUS

Once a systematic FoCUS exam is performed in the acutely hypotensive patient, any abnormal anatomic, physiologic, and hemodynamic findings are evaluated in the context of the patient's clinical history and presentation to diagnose the underlying etiology. Common underlying etiologies of shock and their associated sonographic findings are presented here, grouped by the pathophysiologic categories of shock.

Conclusion

In the acutely hypotensive patient, FoCUS is a powerful bedside tool that can help quickly diagnose the underlying etiology of shock. IRs can utilize this examination in the periprocedural and inpatient setting to guide rescue treatment, monitor response to therapy, and help determine the urgency of procedural management.

Declaration of competing interest

The author reports no potential conflict of interest.

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