急診超聲對(duì)于休克患者鑒別診斷(劉繼海)課件

急診科醫(yī)生主導(dǎo)的床旁超聲技術(shù)在急診臨床中的應(yīng)用2015-4急診科醫(yī)生主導(dǎo)的床旁超聲技術(shù)在急診臨床中的應(yīng)用1主要內(nèi)容急診超聲和普通超聲的區(qū)別？以不明原因休克患者RUSH檢查為例進(jìn)一步闡釋急診超聲的重要性急診超聲的未來(lái)發(fā)展方向？主要內(nèi)容急診超聲和普通超聲的區(qū)別？2急診超聲技術(shù)的開(kāi)展帶來(lái)的沖擊“爭(zhēng)地盤”或“搶飯碗”——該不該做？“資質(zhì)問(wèn)題”與“收費(fèi)問(wèn)題”——如何做？“難做嗎”與“做得準(zhǔn)嗎”——培訓(xùn)與質(zhì)量控制如何解決？急診超聲技術(shù)的開(kāi)展帶來(lái)的沖擊“爭(zhēng)地盤”或“搶飯碗”——該不該3急診超聲vs.普通超聲急診醫(yī)生床旁超聲檢查旨在最短的時(shí)間內(nèi)得到明確的診斷線索（帶著問(wèn)題進(jìn)行超聲檢查）:患者各漿膜腔有液體嗎?患者有腹主動(dòng)脈瘤嗎?患者有宮內(nèi)妊娠嗎?患者有深靜脈血栓嗎?患者的心臟在收縮嗎?正常還是異常?急診超聲vs.普通超聲急診醫(yī)生床旁超聲檢查旨在最短的時(shí)間4急診超聲應(yīng)用范疇表2.1CCEP急診超聲基本應(yīng)用2013創(chuàng)傷超聲重點(diǎn)評(píng)估腹主動(dòng)脈超聲重點(diǎn)評(píng)估心臟急診重點(diǎn)超聲超聲引導(dǎo)操作技術(shù)氣道急診超聲評(píng)估表2.2CCEP急診超聲高級(jí)應(yīng)用2013肺急診重點(diǎn)評(píng)估外周血管急診重點(diǎn)評(píng)估腹部急診重點(diǎn)評(píng)估婦產(chǎn)科急診重點(diǎn)評(píng)估陰囊急診評(píng)估眼睛急診評(píng)估急診超聲應(yīng)用范疇表2.1CCEP急診超聲基本應(yīng)用2015與醫(yī)療質(zhì)量息息相關(guān)危重患者的快速有針對(duì)性的超聲檢查，提高診斷效率:FAST,AAA,CardiacinPEAorhypotension改進(jìn)患者的流程，減少急診滯留時(shí)間:DVT,Pelvicsonoinearlypregnancy幫助我們完成一些操作，降低風(fēng)險(xiǎn):Centrallines,abscesses,LPs與醫(yī)療質(zhì)量息息相關(guān)危重患者的快速有針對(duì)性的超聲檢查，提高診斷6急診超聲有別于傳統(tǒng)的超聲檢查傳統(tǒng)的超聲檢查更加注重某個(gè)臟器病變的檢查和描述，急診超聲則從臨床出發(fā)，有目的的對(duì)急診患者進(jìn)行超聲的重點(diǎn)掃查，對(duì)于患者的疾病狀態(tài)和臟器功能狀況做出更為直觀的評(píng)價(jià)，并根據(jù)檢查的結(jié)果對(duì)患者進(jìn)一步治療和處置提出指導(dǎo)意見(jiàn)?！杉痹\醫(yī)師主導(dǎo)的超聲檢查技術(shù)，被譽(yù)為“急診醫(yī)師的可視聽(tīng)診器”——評(píng)估危重癥患者病情、對(duì)于危及生命的急診疾病做出快速的診斷提高了急診患者的診治效率——引導(dǎo)臨床侵入性操作及指導(dǎo)相關(guān)急診狀況的處置等，有效降低了侵入性操作并發(fā)癥的發(fā)生率急診超聲有別于傳統(tǒng)的超聲檢查傳統(tǒng)的超聲檢查更加注重某個(gè)臟器病7病例24歲女性，58公斤，既往健康，僅口服避孕藥。因“暈倒”被急救車送入院。病人意識(shí)模糊，病史有限。GCS（格拉斯哥昏迷評(píng)分）5-6，BP73/42，脈搏80次/分，體溫38.3℃，SpO292%（在吸氧4升/分鐘的情況下），呼吸26次/分，大汗，右小腿及腳部明顯腫脹。胸片無(wú)明顯異常。心電圖——竇性心律，血糖4.3mM/L。病例24歲女性，58公斤，既往健康，僅口服避孕藥。因“暈倒”8可能的診斷LeftventricularfailureTensionpneumothoraxHemoperitoneumAnaphylaxisSeveredehydrationNeurogenicshockCardiactamponadeValvulardysfunctionPulmonaryembolusOccultmedicationerrororoverdoseSepsisRupturedaneurysmAorticdissectionMyocardialischemia/infarctionThyrotoxicosisAdrenalfailureDysrhythmiaAutonomicdysfunctionOccultgastrointestinalbleedMesentericischemiaAbdominalinflammation

可能的診斷LeftventricularfailureT9RUSHExamThistechnologyisidealinthecareofthecriticalpatientinshock,andthemostrecentACEPguidelinesfurtherdelineateanewcategoryof‘‘resuscitative’’ultrasound.Step1:Thepump（泵）Step2:Thetank（血容量）Step3:Thepipes（血管）

RUSHExamThistechnologyisid10急診超聲對(duì)于休克患者鑒別診斷(劉繼海)課件11Step1—EvaluationofthePump‘‘Effusionaroundthepump’’:evaluationofthepericardium‘‘Squeezeofthepump’’:determinationofgloballeftventricularfunction‘‘Strainofthepump’’:assessmentofrightventricularstrainStep1—EvaluationofthePump‘12EvaluationofthePumpEvaluationofthePump13NormalsubxiphoidNormalsubxiphoid14NormalparasternallongNormalparasternallong15NormalparasternalshortLateralwallNormalparasternalshortLatera16Normalparasternalshort

atlevelofaorticvalveNormalparasternalshort

atl17Normalapical4LateralwallNormalapical4Lateralwall18Normalapical2AnteriorwallNormalapical2Anteriorwall19PericardialeffusionPericardialeffusion20CardiactamponadeCardiactamponade21‘‘Squeezeofthepump’’determinationof‘‘howstrongthepumpis?”avisualcalculationofthepercentagechangefromdiastoletosystoleMotionofanteriorleafletofthemitralvalvecanalsobeusedtoassesscontractility.‘‘Squeezeofthepump’’determi22NormalparasternallongNormalparasternallong23NormalparasternalshortLateralwallNormalparasternalshortLatera24AneasysystemofgradingTojudgethestrengthofcontractionsasgood,withthewallsoftheventriclecontractingwellduringsystole;Poor,withtheendocardialwallschanginglittleinpositionfromdiastoletosystole;Intermediate,withthewallsmovingwithapercentagechangeinbetweentheprevious2categories.AneasysystemofgradingToj25BenefitsKnowingthestrengthofleftventricularcontractilitywillgivetheEPabetterideaofhowmuchfluid‘‘thepump’’orheartofthepatientcanhandle,beforemanifestingsignsandsymptomsoffluidoverload.Incardiacarrest,theclinicianshouldspecificallyexamineforthepresenceorabsenceofcardiaccontractions.BenefitsKnowingthestrengtho26‘‘Strainofthepump’’Onbedsideechocardiography,thenormalratioofthelefttorightventricleis1:0.6.Theoptimalcardiacviewsfordeterminingthisratioofsizebetweenthe2ventriclesaretheparasternallongandshort-axisviewsandtheapical4-chamberview.‘‘Strainofthepump’’Onbedsi27RightVentricleStrainRightVentricleStrain28ThrombusinRAThrombusinRA29DifferentialDiagnosisMassivePESmallerandrecurrentpulmonaryemboliCorpulmonalePrimarypulmonaryarteryhypertensionAcuterightheartstrainthusdiffersfromchronicrightheartstraininthatalthoughbothconditionscausedilationofthechamber,theventriclewillnothavethetimetohypertrophyifthetimecourseissudden.‘‘Evaluationofthepipes”DifferentialDiagnosisMassive30Step2:EvaluationoftheTank‘‘Fullnessofthetank’’:evaluationoftheinferiorcavaandjugularveinsforsizeandcollapsewithinspiration‘‘Leakinessofthetank’’:FASTexamandpleuralfluidassessment‘‘Tankcompromise’’:pneumothorax‘‘Tankoverload’’:pulmonaryedemaStep2:EvaluationoftheTank31EvaluationoftheTankEvaluationoftheTank32‘‘Fullnessofthetank’’‘‘Fullnessofthetank’’33M-modeDopplerM-modeDoppler34Howtodetermine？AsmallercaliberIVC(<2cmdiameter)withaninspiratorycollapsegreaterthan50%roughlycorrelatestoaCVPoflessthan10cmofwater.Thisphenomenonmaybeobservedinhypovolemicanddistributiveshockstates.AlargersizedIVC(>2cmdiameter)thatcollapseslessthan50%withinspirationcorrelatestoaCVPofmorethan10cmofwater。Thisphenomenonmaybeseenincardiogenicandobstructiveshockstates.Howtodetermine？Asmallercal35HighcardiacfillingpressureHighcardiacfillingpressure36TwocaveatstothisruleexistThefirstisinpatientswhohavereceivedtreatmentwithvasodilatorsand/ordiureticspriortoultrasoundevaluationinwhomtheIVCmaybesmallerthanpriortotreatment,alteringtheinitialphysiologicalstate.Thesecondcaveatexistsinintubatedpatientsreceivingpositivepressureventilation,inwhichtherespiratorydynamicsoftheIVCarereversed.Twocaveatstothisruleexist37‘‘Leakinessofthetank’’FASTexamandpleuralfluidassessmentIntraumaticconditions,asaresultofa‘‘holeinthetank,’’leadingtohypovolemicshock.Innontraumaticconditions,accumulationofexcessfluidintotheabdominalandchestcavitiesoftensignifies‘‘tankoverload,’’Ininfectiousstates,pneumoniamaybeaccompaniedbyacomplicatingparapneumonicpleuraleffusion,andascitesmayleadtospontaneousbacterialperitonitis.‘‘Leakinessofthetank’’FAST38RightupperquatrantRightupperquatrant39LeftupperquadrantLeftupperquadrant40PelvicfreefluidPelvicfreefluid41‘‘Tankcompromise’’:pneumothorax‘‘Tankcompromise’’:pneumotho42pneumothoraxpneumothorax43‘‘Tankoverload’’:pulmonaryedemaToassessforpulmonaryedemawithultrasound,thelungsarescannedwiththephased-arraytransducerintheanterolateralchestbetweenthesecondandfifthribinterspaces.ThepresenceofBlinescoupledwithdecreasedcardiaccontractilityandaplethoricIVConfocusedsonographicevaluationshouldpromptthecliniciantoconsiderthepresenceofpulmonaryedemaandinitiateappropriatetreatment.‘‘Tankoverload’’:pulmonarye44B-linesB-lines45Step3—EvaluationofthePipes‘‘Ruptureofthepipes’’:aorticaneurysmanddissection‘‘Cloggingofthepipes’’:venousthromboembolismStep3—EvaluationofthePipes46AAAAmeasurementofgreaterthan3cmisabnormalanddefinesanabdominalaorticaneurysmAAAAmeasurementofgreaterth47AorticDissectionTheparasternallong-axisviewoftheheartpermitsanevaluationoftheproximalaorticroot,andameasurementofmorethan3.8cmisconsideredabnormal.AorticDissectionTheparastern48AorticDissectionAorticDissection49‘‘Cloggingofthepipes’’:venousthromboembolism‘‘Cloggingofthepipes’’:ven50SummarySummary51病例224歲女性，58公斤，既往健康，僅口服避孕藥。因“暈倒”被急救車送入院。病人意識(shí)模糊，病史有限。GCS（格拉斯哥昏迷評(píng)分）5-6，BP73/42，脈搏80次/分，體溫38.3℃，SpO292%（在吸氧4升/分鐘的情況下），呼吸26次/分，大汗，右小腿及腳部明顯腫脹。胸片無(wú)明顯異常。心電圖——竇性心律，血糖4.3mM/L。病例224歲女性，58公斤，既往健康，僅口服避孕藥。因“暈倒52急診超聲評(píng)估結(jié)果（1）心臟收縮力好，未見(jiàn)明顯心包積液，無(wú)右室勞損表現(xiàn)；下腔靜脈直徑<2cm，吸氣變異率>50%，無(wú)漿膜腔積液主動(dòng)脈正常，下肢靜脈未見(jiàn)血栓，右下肢腹股溝區(qū)明顯紅腫右下肢蜂窩織炎，感染性休克急診超聲評(píng)估結(jié)果（1）心臟收縮力好，未見(jiàn)明顯心包積液，無(wú)右室53急診超聲評(píng)估結(jié)果（2）心臟收縮力好，未見(jiàn)明顯心包積液，無(wú)右室勞損表現(xiàn)；下腔靜脈直徑<2cm，吸氣變異率>50%，盆腔積液，超聲引導(dǎo)下穿刺抽出不凝血主動(dòng)脈正常，下肢靜脈未見(jiàn)血栓宮外孕破裂出血急診超聲評(píng)估結(jié)果（2）心臟收縮力好，未見(jiàn)明顯心包積液，無(wú)右室54急診超聲評(píng)估結(jié)果（3）心臟收縮力好，未見(jiàn)明顯心包積液，可見(jiàn)右室擴(kuò)大表現(xiàn)，右室心肌不肥厚；下腔靜脈直徑=2cm，吸氣變異率<50%，未見(jiàn)多漿膜腔積液表現(xiàn)主動(dòng)脈正常，下肢靜脈可見(jiàn)血栓大面積肺栓塞可能急診超聲評(píng)估結(jié)果（3）心臟收縮力好，未見(jiàn)明顯心包積液，可見(jiàn)右55急診超聲未來(lái)發(fā)展方向超聲技術(shù)的發(fā)展帶來(lái)變革更加注重臟器功能連續(xù)評(píng)估被越來(lái)越多的急診醫(yī)師所掌握并指導(dǎo)臨床急診超聲未來(lái)發(fā)展方向超聲技術(shù)的發(fā)展帶來(lái)變革56急診醫(yī)學(xué)的明天更美好急診醫(yī)學(xué)的明天更美好57急診科醫(yī)生主導(dǎo)的床旁超聲技術(shù)在急診臨床中的應(yīng)用2015-4急診科醫(yī)生主導(dǎo)的床旁超聲技術(shù)在急診臨床中的應(yīng)用58主要內(nèi)容急診超聲和普通超聲的區(qū)別？以不明原因休克患者RUSH檢查為例進(jìn)一步闡釋急診超聲的重要性急診超聲的未來(lái)發(fā)展方向？主要內(nèi)容急診超聲和普通超聲的區(qū)別？59急診超聲技術(shù)的開(kāi)展帶來(lái)的沖擊“爭(zhēng)地盤”或“搶飯碗”——該不該做？“資質(zhì)問(wèn)題”與“收費(fèi)問(wèn)題”——如何做？“難做嗎”與“做得準(zhǔn)嗎”——培訓(xùn)與質(zhì)量控制如何解決？急診超聲技術(shù)的開(kāi)展帶來(lái)的沖擊“爭(zhēng)地盤”或“搶飯碗”——該不該60急診超聲vs.普通超聲急診醫(yī)生床旁超聲檢查旨在最短的時(shí)間內(nèi)得到明確的診斷線索（帶著問(wèn)題進(jìn)行超聲檢查）:患者各漿膜腔有液體嗎?患者有腹主動(dòng)脈瘤嗎?患者有宮內(nèi)妊娠嗎?患者有深靜脈血栓嗎?患者的心臟在收縮嗎?正常還是異常?急診超聲vs.普通超聲急診醫(yī)生床旁超聲檢查旨在最短的時(shí)間61急診超聲應(yīng)用范疇表2.1CCEP急診超聲基本應(yīng)用2013創(chuàng)傷超聲重點(diǎn)評(píng)估腹主動(dòng)脈超聲重點(diǎn)評(píng)估心臟急診重點(diǎn)超聲超聲引導(dǎo)操作技術(shù)氣道急診超聲評(píng)估表2.2CCEP急診超聲高級(jí)應(yīng)用2013肺急診重點(diǎn)評(píng)估外周血管急診重點(diǎn)評(píng)估腹部急診重點(diǎn)評(píng)估婦產(chǎn)科急診重點(diǎn)評(píng)估陰囊急診評(píng)估眼睛急診評(píng)估急診超聲應(yīng)用范疇表2.1CCEP急診超聲基本應(yīng)用20162與醫(yī)療質(zhì)量息息相關(guān)危重患者的快速有針對(duì)性的超聲檢查，提高診斷效率:FAST,AAA,CardiacinPEAorhypotension改進(jìn)患者的流程，減少急診滯留時(shí)間:DVT,Pelvicsonoinearlypregnancy幫助我們完成一些操作，降低風(fēng)險(xiǎn):Centrallines,abscesses,LPs與醫(yī)療質(zhì)量息息相關(guān)危重患者的快速有針對(duì)性的超聲檢查，提高診斷63急診超聲有別于傳統(tǒng)的超聲檢查傳統(tǒng)的超聲檢查更加注重某個(gè)臟器病變的檢查和描述，急診超聲則從臨床出發(fā)，有目的的對(duì)急診患者進(jìn)行超聲的重點(diǎn)掃查，對(duì)于患者的疾病狀態(tài)和臟器功能狀況做出更為直觀的評(píng)價(jià)，并根據(jù)檢查的結(jié)果對(duì)患者進(jìn)一步治療和處置提出指導(dǎo)意見(jiàn)。——由急診醫(yī)師主導(dǎo)的超聲檢查技術(shù)，被譽(yù)為“急診醫(yī)師的可視聽(tīng)診器”——評(píng)估危重癥患者病情、對(duì)于危及生命的急診疾病做出快速的診斷提高了急診患者的診治效率——引導(dǎo)臨床侵入性操作及指導(dǎo)相關(guān)急診狀況的處置等，有效降低了侵入性操作并發(fā)癥的發(fā)生率急診超聲有別于傳統(tǒng)的超聲檢查傳統(tǒng)的超聲檢查更加注重某個(gè)臟器病64病例24歲女性，58公斤，既往健康，僅口服避孕藥。因“暈倒”被急救車送入院。病人意識(shí)模糊，病史有限。GCS（格拉斯哥昏迷評(píng)分）5-6，BP73/42，脈搏80次/分，體溫38.3℃，SpO292%（在吸氧4升/分鐘的情況下），呼吸26次/分，大汗，右小腿及腳部明顯腫脹。胸片無(wú)明顯異常。心電圖——竇性心律，血糖4.3mM/L。病例24歲女性，58公斤，既往健康，僅口服避孕藥。因“暈倒”65可能的診斷LeftventricularfailureTensionpneumothoraxHemoperitoneumAnaphylaxisSeveredehydrationNeurogenicshockCardiactamponadeValvulardysfunctionPulmonaryembolusOccultmedicationerrororoverdoseSepsisRupturedaneurysmAorticdissectionMyocardialischemia/infarctionThyrotoxicosisAdrenalfailureDysrhythmiaAutonomicdysfunctionOccultgastrointestinalbleedMesentericischemiaAbdominalinflammation

可能的診斷LeftventricularfailureT66RUSHExamThistechnologyisidealinthecareofthecriticalpatientinshock,andthemostrecentACEPguidelinesfurtherdelineateanewcategoryof‘‘resuscitative’’ultrasound.Step1:Thepump（泵）Step2:Thetank（血容量）Step3:Thepipes（血管）

RUSHExamThistechnologyisid67急診超聲對(duì)于休克患者鑒別診斷(劉繼海)課件68Step1—EvaluationofthePump‘‘Effusionaroundthepump’’:evaluationofthepericardium‘‘Squeezeofthepump’’:determinationofgloballeftventricularfunction‘‘Strainofthepump’’:assessmentofrightventricularstrainStep1—EvaluationofthePump‘69EvaluationofthePumpEvaluationofthePump70NormalsubxiphoidNormalsubxiphoid71NormalparasternallongNormalparasternallong72NormalparasternalshortLateralwallNormalparasternalshortLatera73Normalparasternalshort

atlevelofaorticvalveNormalparasternalshort

atl74Normalapical4LateralwallNormalapical4Lateralwall75Normalapical2AnteriorwallNormalapical2Anteriorwall76PericardialeffusionPericardialeffusion77CardiactamponadeCardiactamponade78‘‘Squeezeofthepump’’determinationof‘‘howstrongthepumpis?”avisualcalculationofthepercentagechangefromdiastoletosystoleMotionofanteriorleafletofthemitralvalvecanalsobeusedtoassesscontractility.‘‘Squeezeofthepump’’determi79NormalparasternallongNormalparasternallong80NormalparasternalshortLateralwallNormalparasternalshortLatera81AneasysystemofgradingTojudgethestrengthofcontractionsasgood,withthewallsoftheventriclecontractingwellduringsystole;Poor,withtheendocardialwallschanginglittleinpositionfromdiastoletosystole;Intermediate,withthewallsmovingwithapercentagechangeinbetweentheprevious2categories.AneasysystemofgradingToj82BenefitsKnowingthestrengthofleftventricularcontractilitywillgivetheEPabetterideaofhowmuchfluid‘‘thepump’’orheartofthepatientcanhandle,beforemanifestingsignsandsymptomsoffluidoverload.Incardiacarrest,theclinicianshouldspecificallyexamineforthepresenceorabsenceofcardiaccontractions.BenefitsKnowingthestrengtho83‘‘Strainofthepump’’Onbedsideechocardiography,thenormalratioofthelefttorightventricleis1:0.6.Theoptimalcardiacviewsfordeterminingthisratioofsizebetweenthe2ventriclesaretheparasternallongandshort-axisviewsandtheapical4-chamberview.‘‘Strainofthepump’’Onbedsi84RightVentricleStrainRightVentricleStrain85ThrombusinRAThrombusinRA86DifferentialDiagnosisMassivePESmallerandrecurrentpulmonaryemboliCorpulmonalePrimarypulmonaryarteryhypertensionAcuterightheartstrainthusdiffersfromchronicrightheartstraininthatalthoughbothconditionscausedilationofthechamber,theventriclewillnothavethetimetohypertrophyifthetimecourseissudden.‘‘Evaluationofthepipes”DifferentialDiagnosisMassive87Step2:EvaluationoftheTank‘‘Fullnessofthetank’’:evaluationoftheinferiorcavaandjugularveinsforsizeandcollapsewithinspiration‘‘Leakinessofthetank’’:FASTexamandpleuralfluidassessment‘‘Tankcompromise’’:pneumothorax‘‘Tankoverload’’:pulmonaryedemaStep2:EvaluationoftheTank88EvaluationoftheTankEvaluationoftheTank89‘‘Fullnessofthetank’’‘‘Fullnessofthetank’’90M-modeDopplerM-modeDoppler91Howtodetermine？AsmallercaliberIVC(<2cmdiameter)withaninspiratorycollapsegreaterthan50%roughlycorrelatestoaCVPoflessthan10cmofwater.Thisphenomenonmaybeobservedinhypovolemicanddistributiveshockstates.AlargersizedIVC(>2cmdiameter)thatcollapseslessthan50%withinspirationcorrelatestoaCVPofmorethan10cmofwater。Thisphenomenonmaybeseenincardiogenicandobstructiveshockstates.Howtodetermine？Asmallercal92HighcardiacfillingpressureHighcardiacfillingpressure93TwocaveatstothisruleexistThefirstisinpatientswhohavereceivedtreatmentwithvasodilatorsand/ordiureticspriortoultrasoundevaluationinwhomtheIVCmaybesmallerthanpriortotreatment,alteringtheinitialphysiologicalstate.Thesecondcaveatexistsinintubatedpatientsreceivingpositivepressureventilation,inwhichtherespiratorydynamicsoftheIVCarereversed.Twocaveatstothisruleexist94‘‘Leakinessofthetank’’FASTexamandpleuralfluidassessmentIntraumaticconditions,asaresultofa‘‘holeinthetank,’’leadingtohypovolemicshock.Innontraumaticconditions,accumulationofexcessfluidintotheabdominalandchestcavitiesoftensignifies‘‘tankoverload,’’Ininfectiousstates,pneumoniamaybeaccompaniedbyacomplicatingparapneumonicpleuraleffusion,andascitesmayleadtospontaneousbacterialperitonitis.‘‘Leakinessofthetank’’FAST95RightupperquatrantRightupperquatrant96LeftupperquadrantLeftupperquadrant97PelvicfreefluidPelvicfreefluid98‘‘Tankcompromise’’:pneumothorax‘‘Tankcompromise’’:pneumotho99pneumothoraxpneumothorax100‘‘Tankoverload’’:pulmonaryedemaToassessforpulmonaryedemawithultrasound,thelungsarescannedwiththephased-arraytran