Integrated Multimodal Interpretation

14.1 Core question

Ask:

  • Is the lung congested?

  • Is the systemic venous system congested?

  • What is the dominant cardiac or non-cardiac mechanism?

  • What immediate therapy is required?

  • What parameter should be repeated?

14.2 Practical bedside order

Respiratory: dyspnoea, hypoxaemia

Lung BLUE/B-line score → cardiac → IVC/VExUS → DVT if PE suspected → synthesize.

Haemodynamic: hypotension, shock

Cardiac → IVC/VExUS → lung → DVT if PE suspected → synthesize.

Cardiac arrest

Brief cardiac activity/pericardium/RV assessment → IVC if time permits → lung pneumothorax assessment → synthesize and act. Do not prolong scanning.

Abdominal: pain, distension, AAA, obstruction

eFAST → kidneys → aorta → spleen → optional targeted views → synthesize and escalate.

Acute aortic syndrome

Parasternal long-axis → suprasternal → superior intercostal/small-scale if needed → subxiphoid/abdominal aorta → search for flap, intramural haematoma, ulcer, pericardial effusion, aortic regurgitation, dilatation → urgent CTA/MRA and vascular/cardiac surgery.

Airway

Pre-intubation DARES risk assessment → intubation → ETT confirmation if capnography equivocal → pre-extubation laryngeal assessment → FONA planning if required.

Procedural

Pre-assessment → real-time guidance → post-verification.

14.3 Management framework — target the mechanism

  • Cardiogenic congestion: decongestion, preload optimization, treat cardiac dysfunction, ventilator optimization.

  • Non-hydrostatic pulmonary syndrome: treat primary pulmonary or inflammatory process; avoid over-diuresis.

  • Systemic venous congestion, RV failure/pulmonary hypertension: evaluate RV afterload; use inotropes or vasodilators as appropriate; avoid empiric fluids.

  • Hypovolaemic shock: fluid or blood resuscitation; identify source.

  • Obstructive shock: PE, tamponade, tension pneumothorax: targeted anticoagulation or thrombolysis, pericardiocentesis, decompression.

  • Distributive/sepsis: source control, antibiotics, fluid plus vasopressor management.

  • HOCM physiology: fluids; avoid nitrates, diuretics, and inotropes; beta-blockers; cardiology.

  • Elevated MSFP: VExUS is not a simple volume score; address underlying cause.

  • LVDD perioperative/ICU: apply CHEOPS; control rate, rhythm, afterload, preload, ventilation; decongest when safe.

  • Acute aortic syndrome: rapid POCUS triage; urgent definitive imaging and surgical consultation.

  • Airway uncertainty: use DARES as an adjunct to clinical assessment and capnography.