SonoCase: 75 year old coming in unresponsive…

This case highlights an example of how bedside ultrasound can save a life. Period.

It was 330pm. The ring down from EMS was helpful; we knew the equipment we needed to get ready prior to arrival. “75 year old female, last seen normal at 2pm by family found unresponsive on the carpeted ground of her bedroom, O2 sat 94% and placed on 100% non-rebreather (NRB), shallow breaths at 12/min, weak carotid pulses with one IV access and fluids running, HR 120, blood pressure 60/p, ETA 5 minutes.” Intubation equipment, central access kit, arterial line set-up, and ultrasound machine – ready. Upon arrival, EMS states they have no advanced directive (aka full code until proven otherwise – to social worker: “please let us know when family arrives.”

In the ED…patient’s airway is unobstructed with a nasopharyngeal airway in place, O2 sat 99% on NRB, breathing shallow, weak pulse, BP now 90s. She is poorly responsive, moaning/ opening eyes/moving all extremities to painful sternal rub. Pupils were equal and reactive. She was intubated, and an ultrasound-guided central line was placed with 2 liters of IV fluids hung and running, and the cardiac monitor showing sinus tachycardia. While the arterial line was being placed, as we are waiting for the results of istat labs to come back, we perform a pseudo-RUSH exam: E-FAST, IVC, Aorta – with that we can rule out tension pneumothorax, sudden pump failure suggestive of acute myocardial infarction, tamponade, intraperitoneal fluid/trauma, abdominal aortic aneurysm and also assess the volume status. It took about 2-3 minutes tops. Below are the images:

E-FAST: clinically, we knew there likely wasn’t a tension pneumothorax and there was lung sliding bilaterally at the 2nd intercostal space midclavicular line for 4 respiratory cycles. No images here, you just have to trust me.

RUQ:

LUQ:

Ok, so there is no obvious intraperitoneal free fluid, and since EMS was guiding her respirations with BVM, it’s no big surprise seeing that big stomach on the LUQ view.

SX:

Great contractility, and no evidence of hypokinesis, which is actually quite surprising given her age, as I always expect some with a 75 year old.

IVC:

Definitely low volume – also not a surprise given her shock state and SX view above, I doubted that she was in CHF failure.

Aorta:

Hello!!!! Ok, we have our answer. Let’s just stop here, no need for a suprapubic view because, well, who cares?! We know that if an abdominal aortic aneurysm ruptures, it bleeds into the retroperitoneum, so the FAST will be negative, unless there is A LOT of blood that spills over. ┬áDuring this time we got istat labs back: Hct 24, Cr 2, INR 1, troponin 0.03. We immediately ordered blood products and called a stat vascular surgery page. Her family arrived and confirmed her code status, stating she had a history of “mild” hypertension only. She was also someone who was a prisoner during the Vietnam war. She went to the OR and lived – which also surprised me given her age, but she was a survivor, strong, with good enough reserve to withstand this stress. She was in the ED for a total of 28 minutes.

This case highlights the need for bedside US in the evaluation of the altered mental status patient and those in shock, as well as procedural guidance. You don’t need to finish the RUSH if you get a diagnosis, but should see it through if you still are unclear about the etiology of shock.

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