They describe it best: ” ….60-year-old male who collapsed at work and remained unresponsive. They state that there was bystander CPR and a lot of freaking out by coworkers. The only past history they have was from a coworker who thought he had high blood pressure. There was also a witness who told them he was just walking, then doubled over and collapsed without saying a thing. No one knew if he had any symptoms earlier in the day. Paramedics state he was initially in a PEA rhythm at a rate of 120 bpm on the monitor. They started an IV, gave him a 500cc saline bolus, intubated him, and have given three rounds of epi. They estimate a 15 minute down time prior to their arrival and a 10 minute transport time with no return of spontaneous circulation. In fact, things are going in the opposite direction as he has been in asystole for the past five minutes.
They move him onto the bed where your EMT takes over CPR. You note good and symmetric assisted breath sounds via the ET tube, but minimal palpable femoral pulse despite what appears to be good CPR to the tempo of the Bee Gees hit “Staying Alive”. On the monitor there is asystole in two leads. Pupils are fixed and dilated despite no atropine having been received. Things are not looking promising.
You request saline wide open and a final round of epinephrine while you take a look for cardiac motion with the ultrasound machine. To minimize interruption of CPR you don’t have the EMT pause until you are completely ready to look. You also have the RT hold respirations to avoid any artifact. There is no cardiac motion. You verbalize this to your team. The heart does not appear dilated and there is no pericardial effusion. You ask aloud, “anyone have any other suggestions” prior to calling the time of death.
Of course you next wonder what did him in: MI, PE, something else… His belly looks pretty protuberant, so you decide to take a quick look at his abdomen to check for free fluid. What you see is shown in the two images below. “
What do you think killed this gentleman? Trust me, you want to read more and see what exactly the ultrasound image is - as it is quite an interesting finding: go here.
For a discussion from a prior post on ultrasound during cardiac arrest, go here.
In case you all were unaware, Dr. Kasia Hampton is REALLY into ultrasound. She is a resident in emergency medicine and is teaching her colleagues how to use it. She has case after case of great findings, quick pick-ups, and lives saved and management changed due to that little old ultrasound machine. She even has another twitter/blog, called @tres_EUS - a site for residents interested in ultrasound cases/leadership/research/etc. She emailed me this case that I thought was a fabulous use of ultrasound and actually shows what I harped on and on about with EMCrit on a recent podcast on FAST scans highlighted in our SonoTips and Tricks on FAST scan upper quadrants.
“25 yo male was found unresponsive per bystanders. Upon EMS arrival he was noted to have multiple stab wounds to the upper extremities and chest. Initial set of vitals revealed tachycardia without hypotension. Patient was intubated at the scene “for airway protection”. Mechanically ventilated upon ED arrival with the following vitals: BP 135/90 mmHg, HR 105 BPM, respirations 16/min, SpO2 100%, T 35.8 C. GCS 3T. During secondary survey found to have one stab wound to the left anterior chest (inferior to the nipple), and second stab wound to the right posterior chest (lateral to the inferior aspect of the scapula). Additional two stab wounds to both shoulders were superficial and were no longer bleeding. No apparent abdominal (wall) injuries were noted. Abdomen was non-distended and soft.
The RUQ FAST scan:
FAST ultrasound evaluation was performed after the patient was log-rolled in both directions – first to the left and then to the right. Subsequently the patient was taken to CT scan. He remained hemodynamically stable. Below the comparative findings of FAST vs CT scans.
perihepatic free fluid
perihepatic free fluid
no pericardial effusion
no pericardial effusion
no free fluid
trace perisplenic free fluid
no free fluid
no free fluid
Given stab wound to left anterior chest with presence of free fluid in the abdomen (with hepatic and splenic injuries identified on CT), patient was taken to the operating room. Injury to pericardium itself without pericardial effusion was suspected on CT. During the surgical exploration it appeared that the stab wound to the left chest only nicked the pericardium (no blood within pericardial sac), while penetrating the left diaphragm, left lobe of the liver, stomach, spleen and pancreatic body.
This case illustrates a few important concepts:
The ultimate importance of visualizing the paracolic gutter around inferior pole of the right kidney on FAST ultrasound exam;
The dilemma of performing FAST scans after the patient has been log-rolled (in particular to the left side, while less important if rolled onto the right);
The superiority of Secondary UltraSonographic Survey In Trauma (SUSS IT) over clinical exam for non-suspected injuries.
In this particular case I wonder if the trace perisplenic free fluid would have been identified on FAST performed before log-rolling? Additionally, it is quite amazing how misleading was the clinical secondary survey in comparison to FAST findings and intra-operative discoveries. ”
An article that just recently came to my attention made me start to think a little bit about how we teach how to do the FAST scan. In a prior post, I discuss the RUQ and LUQ details – to ensure to not miss any amount of free fluid that should be seen on the FAST scan, keeping in mind it’s limitations. Then, I read this article in the EMJ online First from April 2012 that discusses a case of an ‘unusually’ positive FAST scan, but when reading about the injury and the location, I am not surprised about the location of free fluid development. Hind-sight is 20/20, but it highlights a few key concepts that should always be addressed: look for free fluid in the REGION on the RUQ and LUQ, not only between the liver/spleen and kidneys AND serial FAST scans for any patient where the mechanism suggests a risk for intra-abdominal injury (particularly if you are not going to CT the patient) – I do this frequently in the patients who come in drunk as all get-out where I cannot rely on my physical exam or the pediatric population where radiation would be best avoided if possible.
So, this case that I just had the other day is an example of an “oldy but goody” reason why bedside ultrasound rocks, especially in the blunt trauma victim with multiple injuries. 40 year-old motorcycle helmeted driver going moderate speed was T-boned by a car and fell onto his left side. He c/o severe left leg pain and mild left lower back pain, with STABLE (and yes, I mean, stable/normal/not worrisome vitals – HR 72, RR 16, BP 148/90, O2 sat 97%RA) with a clear primary trauma survey, and a secondary that revealed a small abrasion on his cheek, no left sided chest wall tenderness, nontender abdomen, no pelvis instability, an obvious deformed open fracture of his left tibia/fibula, and left lower posterior rib cage tenderness without crepitance or bruising. An E-FAST was done… Continue reading →