SonoCase: 46yo shortness of breath – guest post by Jacob Avila @UltrasoundMD #FOAMed

Our newest guest post is by one of the best emergency medicine resident educators I know – of course, you dont want to miss his educational pearls on twitter too – Dr. Jacob Avila. He discusses a case that illustrates how bedside ultrasound can help in your unexplained short of breath patient, and even cancel that triage bias that your attending can do to sway you away from the truth. Let’s give it to Dr. Avila for highlighting (with a great literature review) how ultrasound can help you too. Here it is – enjoy! (note: not all images were of this patient, but were taken from other resources)

“You arrive to the emergency department for your first night shift of the month, and as you place your bag on the desk, the attending walks towards you with a chart in his hand. “Do you mind seeing this patient? It’s a COPD’er with dyspnea.  It’s probably just a COPD exacerbation.”  You look at the chart and see that it’s a 46 year old female with shortness of breath.  As you walk into the room, you notice the patient appears slightly pale, is afebrile, has an O2 saturation of 91% and is tachycardic in the 110’s with a blood pressure of 105/76, temperature of 98.5° and respiratory rate of 26.  While taking the history, you note that the patient is a smoker and recently returned from a 12 hour car ride to see relatives.  Suspecting that this may be something other than simple COPD exacerbation, you grab your ultrasound machine and start with the cardiac echo (as described in the RADiUS protocol) and are able to get the following image:

This apical 4-chamber view shows severe right heart dilation, defined as a RV:LV ratio >1.  However, you remember that the patient has a history of COPD, and chronic pulmonary hypertension can cause chronic right ventricular dilation1.  At that moment, the patient becomes hypotensive with a systolic blood pressure in the 70’s and develops severe respiratory distress. What should we do?

Early diagnosis of a pulmonary embolism (PE) is exceedingly important, as two thirds of patients with mortality associated with a PE die within the first hour of their presentation2, and intuitively, those who are treated earlier generally have a better prognosis 3.  The definitive diagnosis of a PE requires the use of a CT scanner 4, but in a patient who is unstable, like this one, that isn’t an option. Looking at the right ventricular to left ventricular ratio is a maneuver that can rapidly change your differential diagnosis or confirm what you previously suspected. A recent study by Dresden et al found right ventricular dilatation identified by emergency physicians had a specificity of 98% for a PE.  That number is impressive, but when you look at the methodology section of the publication, only 10% of the patients they included had coexisting COPD, and all of the false positives in the study were in patients with COPD5.   One  technique that may help differentiate between chronic and acute dilation is looking at the RV free wall in the subxiphoid view while in end diastole. A free wall size >0.5 cm is more likely to be chronic RV dilation6i. However, this view is not always possible in all patients.  Another echo sign you could look for is the McConnell sign (apical winking of the right ventricle during systole), which previously was reported to have an impressive 94% specificity and 77% sensitivity for an acute PE7l, but a subsequent and larger study found the McConnell sign to be only 70% sensitive and 33% specific for a PE8. Take a look at what the McConnell sign looks like”

 

Another, less commonly seen finding would be directly seeing the clot in the right atrium (RA) or in the pulmonary arteries.

Clot in RA:

RA clot labeled

Clot in pulmonary artery:

Pulm clot labeled

Of more practical use are two other sonographic findings: Deep venous thrombosis (DVT) and distal pulmonary infarction.

In a study that included 199 examinations, bedside 2-point compression evaluation of the greater saphenous/femoral vein junction and the popliteal veins of patients with suspected DVT was found to be 100% sensitive and 99% specific for DVT 9.   However, it is possible for a patient to present with an acute PE and have a negative DVT, and only about 40-50% of patients with DVT’s will end up having a PE10, 11

DVT on one side diagnosed by noncompressible vein:

More recently, lung ultrasound has been explored for the assessment of a suspected PE. A recent systematic review and meta-analysis by Squizzato et al which included 10 studies and a total of 887 patients found lung ultrasound to have a mean sensitivity of 87% and a mean specificity of 82% for acute PE12.  What they looked for in the lung was the presence of triangular, wedge or rounded hypoechoic, pleural based lesions.  These lesions are thought to be due to embolic occlusions that resulted in either focal atelectasis with extravasation of blood or focal infarction of the lung parenchyma . However, they state in their publication that “Several methodological drawbacks of the primary studies limit any definite conclusion”.

Lung infarction:

 

Instead of looking at just one specific sonographic finding for the diagnosis of acute PE, a better method may the use of multi-organ sonography.  Recently, Nazerian et al. published a study utilizing multi-organ sonography in the diagnosis of PE.  This study used echo, lung and DVT ultrasound to diagnose PE and found that when the three ultrasounds were combined, they yielded a sensitivity of 90%, which was significantly higher than each of the exams by themselves13.

Like any physical exam finding, lab reports or other radiographic assessments, the sonographic analysis of a patient with a suspected pulmonary embolism should be used as part of your diagnostic quiver, and not the silver bullet.  Any of the above mentioned ultrasound findings of acute PE can potentially be found in other,  non-PE causes of dyspnea.  DVT’s can just be DVT’s, RV enlargement can be chronic or from an RV infarction, and subpleural fluid collections can be seen in contusions, pneumonia  and cancer.  This doesn’t mean not to use it though.  Just think about all the other tests we use in the emergency department, such as EKG’s, chest x-rays, troponins, BNP, and the d-dimer.  All of these can be abnormal in PE and in non-PE entities.

Now back to our patient.  She is a 46 year-old female with COPD that had right heart enlargement, which we learned above can be  seen in COPD without the presence of a PE.  You were unable to get a good subcostal view of the heart to measure the lateral wall, mostly because the  patient did not tolerate being laid flat.  You move on to the lungs and in the lower right thorax and there you find two hypoechoic, pleural based lesions.  Heparin and a CT scan are ordered, and the CT scan shows a large clot located in the right main pulmonary artery.

Here is the CT scan showing the clot:

Avila_Clot in pulmonary artery CT

To see a recent podcast by Ultrasoundpodcast on multi-organ US for PE, go here.

References:

  1. Otto, Catherine M.. Textbook of clinical echocardiography. 5th ed. Philadelphia, PA: Elsevier/Saunders, 2013. Print. p 247
  2. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002;121:877-905
  3. Jelinek GA, Ingarfield SL, Mountain D, et al. Emergency department diagnosis of pulmonary embolism is associated with significantly reduced mortality: a linked data population study. Emerg Med Australas. 2009;21:269-276
  4. Goldhaber SZ, Bounamenaux H. Pulmonary embolism and deep vein thrombosis. Lancet 2012:379:1835-46
  5. Dresden S1, Mitchell P2, Rahimi L2, Leo M2, Rubin-Smith J2, Bibi S2, White L3, Langlois B2, Sullivan A4, Carmody K5 Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med. 2014 Jan;63(1):16-24. doi: 10.1016/j.annemergmed.2013.08.016. Epub 2013 Sep 27.
  6. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685-713
  7. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 1996;78:469e73.
  8. Casazza F, Bongarzoni A, Capozi A, Agostoni O. Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr. 2005;6:11-4
  9. Crisp JG, Lovato LM, Jang T. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med. 2010;56:601-610
  10. Kearon C. Natural history of venous thromboembolism. Circulation. 2003;107:22-30
  11. Moser KM, Fedullo PF, Littlejohn JK, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis. JAMA 1994;271:223-225
  12. Squizzato A1, Rancan E, Dentali F, Bonzini M, Guasti L, Steidl L, Mathis G, Ageno W. Diagnostic accuracy of lung ultrasound for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost. 2013 Jul;11(7):1269-78. doi: 10.1111/jth.12232.
  13. Nazerian P, et al. Accuracy of Point-of-Care Multiorgan Ultrasonography for the Diagnosis of Pulmonary Embolism.Chest. 2014 May 1;145(5):950-7. doi: 10.1378/chest.13-1083

SonoCase: 60yo blunt chest trauma, 82yo with chest pain- in JEM by @ultrasoundREL

In a recent article in the Journal of Emergency Medicine, Dr. Resa Lewiss and friends, discuss 2 cases of thoracic aortic aneurysm identification by focused cardiac ultrasound. It is a great case report that highlights the need to include the aortic root and descending thoracic aorta in the parasternal long view of your focused cardiac echo.

“A 60-year-old man presented to the emergency department (ED) after a blunt traumatic injury to his back while at work. During the focused cardiac ultrasound examination, the aortic outflow tract distal to the aortic valve appeared enlarged and the aortic root measured 5.49 cm.

Screen Shot 2014-03-04 at 9.16.55 AM

“An 82-year-old man with hypertension presented to the ED with 1 month of chest pain radiating to the back. The focused cardiac ultrasound examination demonstrated enlargement of the descending thoracic aorta at 4.82 cm.”

Screen Shot 2014-03-04 at 9.17.06 AM

SonoCase: 72yo back pain & hypotensive – by Dr. Calvin Hwang @helixcardinal #FOAMus #FOAMed

Another great guest post! – by Dr. Calvin Hwang, aka @helixcardinal  - as well as the senior resident at Stanford/Kaiser EM program who updates the @StanfordEMRes residency twitter feed, provided an excellent case that illustrates a reason/indication to perform bedside ultrasound – especially the Echo/IVC and Aorta applications – illustrating why these applications are imperative to the RUSH protocol - along with good clinical judgement. Enjoy!

“Code 3 ringdown from EMS: 70 yo F coming in with 3 days of chest, back and abdominal pain, hypotensive with SBP in the 70s.

On arrival, patient is grimacing in pain, pale, diaphoretic.  She is otherwise healthy with no past medical history.  Just arrived from Thailand 1 week ago to visit her daughter and had been complaining of pain in her chest, back and abdomen.  Went to a primary care physician where she was noted to be hypotensive and sent to the ED.

Initial vital signs: BP 73/30, HR 110, T37.0, RR 25

Screen Shot 2013-08-22 at 6.21.37 PM

With the trusty bedside ultrasound, I immediately went to where I thought would be the diagnosis: ruptured AAA…..but…..

The abdominal aorta scan : I was shocked when I noticed it to be of normal caliber.  Nevertheless, I worked my way up the abdomen to the subxiphoid view when I saw:

Though it was atypical for the patient to be hypotensive and tachycardic, the presence of a pericardial effusion without tamponade suggested aortic dissection to me.  My attending got on the phone to prepare to transfer the patient while I contacted the radiologist to clear the CT scanner.  Though I attempted to view the descending aorta and aortic outflow tract on a more focused echo in the brief interim through a parasternal approach, I was unable to obtain good windows.  The IVC was plump and the rest of the FAST was negative.  A quick Chest XR was done:

Screen Shot 2013-08-22 at 6.21.01 PM

…..which did not show a wide mediastinum according to radiology.  The patient was whisked away to the CT scanner and within 45 minutes of ED arrival, the diagnosis of a Stanford type A aortic dissection with pericardial effusion (but not tamponade) was confirmed.  This would not have been possible without bedside ultrasound as I think most clinicians would have been falsely reassured by the normal CXR (widened mediastinum only present in 60% of aortic dissections1).

The patient was fluid resuscitated with crystalloid, her BP improved to 100/60 and HR came down to the 80s.  While awaiting transport, I attempted to place an arterial line for close BP monitoring.  However, approximately 60 minutes after ED arrival, the patient became progressively bradycardic and coded.  My institution’s cardiothoracic surgeons were already at bedside and performed a sternotomy with pericardial window.  Despite our efforts, we were never able to obtain return of spontaneous circulation and the patient was pronounced. These patients rarely make it to the ED due to how quickly they can decompensate, but if they do, quickening the diagnosis may help get them the intervention they need (clinical suspicion and appropriate use of bedside ultrasound is key), although a high mortality still exists.

  1. Aldeen A, Rosiere L.  “Focus on: Acute Aortic Dissection.” ACEP News, July 2009.

SonoCase: 32yo shortness of breath – by @Medialapproach #FOAMed

We have had some great additions of guest posts of cases where ultrasound mattered and helped with their diagnosis and treatment. Below is a case from Vince DiGiulio, an EMT and ED tech extraordinaire and more! – also known as@MedialApproach of the medialapproach.com as well as the founder of a great Google+ account on ultrasound. Read his case below and enjoy!
“In this case I was able to nail down the cause of the patient’s symptoms in 5 minutes, and I’m only an EMT whose US teaching has come entirely from online resources like SonoSpot. Here’s the story:

It’s a hot summer’s day and you are working a busy shift in the Minor Care unit of a community ED when a 31 year-old man presents with a chief-complaint of shortness of breath (SOB).

He states that he has been feeling SOB on exertion for the past 3-4 weeks, having attended the walk-in two weeks prior with the same complaint. There he was diagnosed with asthma and given an albuterol MDI, a course of PO steroids, and also a course of PO azithromycin “in case it was something more.” His symptoms had not improved so he decided to attend the ED for another opinion.

From the doorway you see a moderately overweight (5’9” 200#) Caucasian male in no acute distress. He is exhibiting a normal respiratory rate with no elevated work of breathing. His skin is warm and of normal color, but upon closer inspection you’re a bit surprised to notice he is actually moderately diaphoretic. He chalks it up to the outside temperature of 90 F, but it’s a chilly 70 F in the department and he’s been seated in bed for at least 20 minutes. “Hmmm,” you say to yourself.

Vital signs at rest are as follows: HR 115 bpm, RR 20/min, BP 122/68 mmHg, Temp 37.1 C.

On auscultation he has a bit of bi-basilar rales.

After obtaining a history, you head back to your desk to enter some orders when you see that an ECG and CXR were already performed at triage.

32yo M - SOB on Exertion x 3 wks_ECG

[http://sonocloud.org/files/photos/1373606099f1a0ab_o.jpg]

The ECG shows sinus tachycardia, left-atrial abnormality, left-axis deviation, poor R-wave progression, large S-wave in the right-precordial leads, and secondary ST and T-wave changes. This picture is consistent with left-ventricular hypertrophy.

Screen Shot 2013-12-02 at 12.58.36 PM

http://sonocloud.org/files/photos/13736928941892d4_o.jpg]
The CXR was read by radiology as “mild-to-moderate cardiomegaly, new from prior film (2 years ago), consider pericardial effusion.”

This Minor Care case is starting to get a bit more complicated and you’re beginning to wish you had seen the patient with chronic low-back pain instead. Not quite sure what to make of this patient’s presentation and afraid of backing up the whole department while you try to make a hard-sell on this young, otherwise healthy patient to cardiology, you instead grab your trusty ultrasound machine and head for the bedside. Here is what you see.

[http://sonocloud.org/watch_video.php?v=NAHA61SSH3B7]

In this apical 4-chamber view, you first notice that all four chambers are markedly dilated and hypokinetic. Looking specifically at the left-ventricle, it exhibits with severe hypokinesis throughout, maybe with a touch of apical akinesis. Looking closely at the apex of the LV also shows that there is an apical mural thrombus, often seen in patients with akinesis or severe hypokinesis of that region.

 [http://sonocloud.org/watch_video.php?v=SG794W7MBYBG]

As evidenced by the obvious blue jet in the left-atrium, this color-Doppler image of the mitral valve demonstrates significant mitral regurgitation. At formal echocardiography it was graded as “moderate, 2+ mitral regurgitation.”

32yo M Mitral Doppler

[http://sonocloud.org/files/photos/1373605496135c3c_o.jpg]

This pulsed-wave Doppler image shows monophasic flow through the mitral valve with a nearly absent A-wave. This proves that in addition to systolic dysfunction, the patient has significant diastolic dysfunction as well in a restrictive pattern.

[http://sonocloud.org/watch_video.php?v=SK85U7KAMSW1]

Here is a mid-ventricle parasternal short-axis view that further demonstrates the global hypokinesis of the left ventricle. It is also clear that the ventricle is large and dilated, but not hypertrophied. In this patient’s Cardiology echo, his ejection fraction was estimated in the range of 10-15%. I’m an inexperienced echocardiographer, but in addition to global hypokinesis I might specifically see some anterior-wall akinesis here as well.

[http://sonocloud.org/watch_video.php?v=KGUYWXGR2YG2]

This parasternal long axis view offers a final example of the patient’s global hypokinesis, along with a nice shot of the mitral valve. The aortic valve is also in view, but not clearly seen. Notably there is also no sign of pericardial effusion, often visible in this view if present.

So what’s our final impression? Summarizing all of the specific findings listed above, this patient has a dilated cardiomyopathy. While the workup and management of this patient could encompass a week’s worth of posts, here are the main take-home points from this case:

  1. Beware patients who are diaphoretic or tachycardic at rest. Afebrile and in no acute distress, it became essential to find a source of this patient’s few abnormalities on physical exam.
  2. Don’t be afraid of ultrasound in the Minor Care department. We like to talk a lot about the utility of ultrasound during a patient’s resuscitation, but it can be equally useful in an ambulatory setting as well.
  3. Bedside ultrasound expedites care. Without bedside ultrasound this patient would have been waiting around hours (or days) for a formal echo, if it was going to be performed at all.
  4. Sell! Sell! Sell! In most circumstances cardiology would have been very reluctant to come see an otherwise healthy 31 year-old patient, but in this case the bedside images provided immediate and definitive proof that the patient needed specialty care. It also probably gained us some street-cred with the cardiologist who could look at the saved images right in the department.
  5. Shoot first, ask questions later. In a case like this, there is no need to perform an extensive interpretation of your images at the bedside. From the very first view it was clear the patient had a dilated cardiomyopathy, so cardiology was immediately paged and the patient was readied for admission. During that time additional views were quickly obtained for later evaluation, but that first shot told us all we needed to know to make a disposition on the patient.
    As an ECG nerd, I liken it to reading the tracing of a patient with a profound wide-complex tachycardia. At the bedside there is rarely any need to get too fancy differentiating VT from SVT with aberrancy since the WCT algorithm is safe and effective for both, but once the patient is stabilized I can then go back and look for signs of AV-dissociation on the ECG to really prove it was VT.
    You think I noticed the apical thrombus in this patient’s AP4 view? No-way! That’s something Mike Mallin of the Ultrasound Podcast picked up for me when I shared the case with him. I didn’t even know how to read a pulsed-wave Doppler at the time I met the patient, but I knew how to capture the image at the level of the mitral valve so that I could review and learn from it later.

Anyway, thanks to bedside US (and you!) this patient ended up having his dilated cardiomyopathy recognized and promptly treated. Without these surprising images there’s a really good chance this patient would have been symptomatically treated for his SOB in the ED and then discharged back home. If anything, being able to reference these clips gave our emergency physician a very strong card to play in getting cardiology to take the case seriously.”

SonoCase: 61yr old with leg swelling, chronic cough, intermittent chest pressure – by Dr. Torregrossa et al. in @westJEM #FOAMed

This case is one where if I were the doctor, my immediate response may have been hidden from the patient. Inside voice would NOT have stayed in. Wow! Dr. Torregrossa and the team at USC discuss a case published in March 2013 Western Journal of Emergency Medicine of a patient where there obviously was no bedside ultrasound performed for the duration of his symptoms. “How long was that?” you may ask… ONE YEAR! Wow! He saw his doctor (check), he got a chest Xray (check), he got an EKG (check). Good thing he finally got an ultrasound study ….

The case: “61-year-old male with a 1-year history of bilateral lower extremity swelling and a chronic cough was referred to the emergency department (ED) for an abnormal echocardiogram. The patient also reported experiencing intermittent episodes of chest pressure. He stated that he was referred from his doctor after he received a cardiac echocardiography examination that showed possible mitral valve vegetations. On review of systems, he also admitted to intermittent chest palpitations. On physical examination, his vital signs included a blood pressure of 127/75 mmHg, heart rate of 80 per minute and regular, respiratory rate of 18 per minute, pulse oximetry of 98% and temperature of 98.0°F. The rest of the physical examination was normal. An electrocardiogram demonstrated normal sinus rhythm and the chest radiograph was unremarkable. ED bedside ultrasound (EUS) showed….”

To read on the topic so that you will know some of the literature behind it – go here.

SonoCase: 40yo: cough, fever, mylagias – typical viral infection? – By Teresa Wu/Brady Pregerson in EPMonthly #FOAMed

Drs. Teresa Wu and Brady Pregerson (in the current issue of EPMonthly) once again discuss an interesting case that is more than meets the eye, and thankfully they continue their humorous sarcasm and start the case by speaking of an average day in our emergency departments these days: “This is the third time this week that you have had to close your ED. All of the beds in the hospital are full, and your ED is bulging at the seams with sick patients that aren’t going anywhere anytime soon. You are holding 10 admissions at the present moment, and the hallways are lined with patients calling “doctor” every time you walk by. As much as you hate doing so, you concede to the request to close to ambulance traffic and then walk briskly over to the chart rack to see what you can do to help improve the current situation. Your eager intern is right on your heels and says he has a new patient to present to you. “This should be a really simple case,” he spurts out. You raise your eyebrows and bite your tongue.”……

They (meaning, the intern) describe a case of a 40 year old female who has had what seems like an upper respiratory infection for 4 weeks, that’s just not going away, and now with sharp chest pain worse when coughing. While going to evaluate the patient, they give one of the best pearls that all residents  should know: ““Teaching point number one is conservation of energy. One of the best ways to be efficient is to ensure that you minimize the amount of time wasted. If you might need the ultrasound machine, take it with you so you don’t have to walk back out of the room to go get it.” They then proceed to perform the beginnings of the RADIUS study, which highlights Echo, thoracic and IVC ultrasound for the short of breath/dyspneic patient. The patient complains of pain when lying back, which causes the spide-y sense to go up and be confirmed when seeing the below picture on the echo:

Screen Shot 2013-03-25 at 11.34.28 AM

To read more on the case and their great clinical pearls click here to get to EPMonthly’s online site.

To read a prior post emphasizing the need to perform an ultrasound for any presumed or confirmed pericarditis by going through a another case… and some studies, click here.

SonoCase: 57yr old altered mental status, h/o Hep C & TIPS, new murmur – By Dr. Perera & team

In the most recent issue of WestJEM, a very interesting ultrasound case by Drs. Wendler, Schoenberger, Mailhot and Perera was published illustrating that if you dont look, you won’t get the diagnosis! How bedside ultrasound solved the case! Below is only the beginning of the case:

“A 57-year-old Hispanic male presented with a 1-day history of altered mental status. He had a past medical history significant for alcohol abuse, hepatitis C and Child-Pugh Class B cirrhosis. He had undergone TIPS placement an unknown number of years before presentation to the ED. Additionally, he had been previously hospitalized for hepatic encephalopathy due to noncompliance with his medical regimen.

On physical examination, the patient appeared comfortable and calm. He was alert, but oriented to name only. Vitals signs were temperature 98.1°F pulse 78 beats/ min, respiratory rate 16 breaths/min and blood pressure 130/89 mmHg. The patient was noted to have scleral icterus, and his abdominal exam revealed moderate ascites without tenderness, rebound, or guarding. Unexpectedly, on cardiac auscultation, the patient was noted to have a 2/6 systolic and a 2/6 diastolic murmur with ectopy. A 12-lead electrocardiogram (ECG) was obtained in addition to standard laboratory studies to elucidate the cause of the patient’s altered mental status.

The serum white blood cell count was 6,500/mm3 without neutrophilic predominance, hemoglobin of 10 g/dL, BUN of 10 mg/dL and a creatinine of 0.6 mg/dL. The patient was noted to have an elevated ammonia level at138 umol/L. The 12-lead ECG showed normal sinus rhythm with multiple premature atrial contractions. To further assess cardiac function, a bedside EUS was performed…..” (see below)

Oh, but there’s more! The case isnt over, nor the discussion – read more!

SonoCase: 55 yr old healthy male, short of breath, appears ill – guest post by Dr. Viveta Lobo

I’d like to introduce everyone to our amazing Ultrasound Fellow, Dr. Viveta Lobo (otherwise known as “VLo” to our team – of course!). She came to us by way of Drexel, tolerates out antics, appreciates our quirks, and laughs at our jokes. We love her! Enjoy this post about a healthy guy who looked very sick, short of breath, and only bedside ultrasound, using the RADIUS protocol, could help diagnose it so quickly and get the patient what he needs and fast….

I’m about 4 months into my Ultrasound (US) Fellowship at Stanford, and while I am thrilled to have greatly improved my US skills, and image acquisition during a scanning shift, it is in no comparison to the thrill, and satisfaction I felt, after using my bedside US skills to navigate through the following case.

A 55-year-old healthy male, with no past medical history, presents with progressively worse shortness of breath over the past 2 weeks. Within 30 seconds of being in the room, he is getting more short of breath, dusky, diaphoretic, and requiring to now sit up and lean forward while speaking to me in 1 word sentences. He is on a 100% non re-breather, sating about 93%. The rest of his vitals – BP 124/84 RR 41 HR 124 Temp 97.8

Even as a new attending, I was pretty certain, that if I did not figure this out in the next few minutes, this once very healthy patient is going to decompensate, and likely end up with grave morbidity. However, given that he had no known history, I had nothing to go by, except…. I grabbed my US probe, and within 3 minutes, I gained a wealth of information. I first took a look at his chest by using the phased array low frequency probe on each side of his chest in 8 total areas (4 on each side). This is what I see throughout:


…. >2 large B lines bilaterally, rays from the pleural line on the top to the end of the screen.

When I switched to a RUQ and LUQ views, my suspicions were confirmed :
RUQ:
LUQ:

…Now, the US images are on cardiac presets so the resolution is a touch different than what we are used to, but the findings are obvious which heightened my concern for the patient even more: large pleural effusions noted bilaterally. Seen as a black (anechoic) area above the diaphragm. Black is fluid on ultrasound, and you can even see the lung trying to breathe on each of the images above.

Next, I quickly assessed his IVC, and saw a plump dilated IVC, consisted with fluid overload state, which prompted me to stop my nurse from hanging any IV fluids. I then performed a bedside echo:
Subxiphoid view: (placing the phased array low frequency probe in the subxiphoid area and pressing down while flattening the probe, using the liver as an acoustic window to see the heart):

Apical 4-chamber view: (placing the probe just underneath the nipple line, at the point of maximal impulse and angling toward the body center):

…. I was able to rule out a pericardial effusion and cardiac tamponade as well as any significant RV strain to suggest a hemodynamically unstable pulmonary embolism, but I appreciated significant left ventricle dysfunction, and hypokinesis.

I then took a look using the linear probe on the anterior chest wall at the 2nd intercostal space and saw:

So, there is great lung sliding but we see it almost too well! The reason is because fluid is the lover of ultrasound and will allow you to see tissue deep to it better due to enhancing of echoes. There is fluid between the parietal and pleural layers, more and more from superior to inferior chest – on both sides. That’s quite a bit of pleural effusion if it goes all the way up to the upper lung zones! While I was putting the pieces together and realizing the diagnosis, my nurse informs me that his istat troponin comes back elevated. His initial EKG:ekg

…..showed sinus tachycardia with ischemic changes inferior and laterally, with t waves inversions. We also see multiple PVCs. No old one EKG for comparison. Ah, the evolution of an MI on EKG – love it!

So to recap, I have an otherwise healthy gentlemen, with progressive sob, no chest pain, but with positive family history of ACS, with confirmed LV dysfunction on US and bilateral pleural effusions and a positive troponin, and some possible ischemic changes on EKG. Sounds like a post ischemic cardiac event presenting with ventricular infarct! From door to diagnosis in 5 minutes! I placed him on BIPAP, gave him a big shot of Lasix IV, aspirin PO, and called my cardiologist! The patient started to improve after the medication, avoiding intubation. The Chest Xray was then done:

photo (8)….showing bilateral diffuse opacities which could be typical for ARDS.

After a brief cardiology evaluation, my patient was admitted to the CCU and shortly after went to the Cath lab, and was found to have a complete LAD occlusion.

While I initially had a very broad differential including PE, new onset CHF, cardiac tamponade, myocarditis, pneumonia; my bedside ultrasound was quickly able to prioritize my differential, and consult the right service, with a specific question of – should this patient go to the cath lab? Without bedside US, this patient could have easily been a Medical ICU evaluation for respiratory distress, with an extensive work up, including CT Chest, intubation, and more time than the patient needed for a diagnosis to have bee made while we sorted through the differential.

This case is one of many that completely validates bedside ultrasound for me, and my decision to pursue this awesome fellowship!

As a follow up: Patient went on to get an LVAD, and is on the heart transplant list.

SonoTip&Trick: “I can’t tell if it’s a pleural or pericardial effusion.” Really? well here’s a tip…

There was a case a few years back that got a lot of attention. 56 year old hypotensive and the providers could have sworn that he had a pericardial effusion, and thus tamponade because they saw the image below on their AP4 and PSL views. They called the cath lab and the cardiology fellow who also performed their echo thought the same and set it up for the patient to get a pericardial window as he was… well….”unstabley stable” – as one of my mentors would say.

AP4:

Continue reading

SonoCase: 25 yr old positional, pleuritic, chest pain. “It’s just pericarditis” Really?

Had a great case the other week of a patient who was previously healthy (“great” because of what it reminds us all to do with this diagnosis) , and other than a girlfriend who he fought with too frequently causing him to go into panic attacks and hyperventilate, he doesn’t have any other stressors in his life – psychologic or drug-induced (yes, I mean cocaine). He came to the ED c/o positional chest pain, worse when lying flat and breathing in, has been persistent for over a week with a recent viral syndrome but no current fever, cough or respiratory distress. He looked well, but felt tired, had no energy to walk a few blocks and that has been worsening over the week, which is when he got into another fight with his girlfriend about coming into the ED for evaluation. Thankfully, he lost and came in.   Continue reading