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.
“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.”
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.
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:
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.
This case is one of the most interesting cases I have heard about. A true testament to the concept that with bedside US, know what normal looks like well – because if you see something that doesn’t look normal, you may not know what it is sometimes, but it’s not normal and it’s time to explore further. One of our stellar EM residents, Dr. Natatcha Chough, went to the bedside of this patient who was brought by ambulance with appreciable diaphoresis. He was 57 yrs old, c/o gradual onset of chest pressure radiating to his back for 40 minutes (which had resolved after paramedics gave nitroglycerin), feeling light head, with associated shortness of breath, wheezing. He had a history of hypertension and aortic coarctation repaired as a child and at age 20, no history of asthma/COPD, and takes Metoprolol daily.
His vitals: T 36.3 RR 24 HR 83 BP 87/55 O2 sat 93% RA Continue reading
Here’s another crazy case I had in the middle of the night in the ED, a night that was particularly… let’s say… challenging. Lots of patients (about 43 actually) and 2 thankfully great residents, and one other ED attending. We were busy supervising a chest tube placement, while overseeing the trauma next door and finishing our charts on other patients so they can be dispo’d (yup, multi-tasking at its best – [or worst, ya never know]) and we get a ring down of a 45 year old in acute respiratory distress placed on non-rebreather with subsequent vitals: HR 130s BP 80s/50 RR 38 90%O2 sat. Continue reading
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