This case is one of those cases that make me so proud of the residents I work with…. Drs. Brianne Steele and Cesar Avila identified the need for a RUSH exam, but didn’t stop there – they noticed something during their RUSH and proceeded with another evaluation – obtaining the surprising diagnosis below, saving him time in the emergency department and canceling his CT scan that didn’t need to be done, which I then conclude controls his healthcare charge. period.
70 year old male with a history of (ready for it…) Continue reading
The great thing about bedside ultrasound is that you can get a really REALLY good idea of what is going on with a patient within 5-10 minutes of their arrival, particularly patients who can’t tell you whats going on (whether it’s because they are lethargic and tachypneic – like this case – or altered, unconscious, or speak another language) , but, because you are a great doc, you do know by just walking through the doorway and looking at the patient that he is S.I.C.K. This case discusses exactly that and highlights the RUSH protocol, (see my prior post on the evidence based approach to the RUSH) ,but also how interpreting those applications when correlating to your exam and clinical history is key and adds greatly to your evaluation of the patient.
60 yr old guy (with an amazingly nice wife and family) with a history of cutaneous T-cell lymphoma (chemo/radiation 3 months earlier), Sezary syndrome (with chemo) and Sjogren’s syndrome walks in (yes, thats right, walks in…) to the emergency department waiting room, leaning on his wife after just getting off a plane from Seattle (about a 3 hour flight) after a 1 week cruise. Continue reading
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
This case was diagnosed in 10 minutes of patient evaluation according to the resident on our ultrasound elective who performed the scan and the team caring for him in the emergency department. The team knew the diagnosis and, therefore, knew what to order quickly. The patient came with his wife by private vehicle into the triage area of the waiting room where he complained of feeling very weak, more and more over the last 2 days, gradual onset, and said he couldn’t catch his breath with just a few steps. His appetite was poor and wasn’t eating or drinking much, denies chest pain/fever/vomiting/diarrhea or bloody/dark stools. He has a history of metastatic lung cancer (on chemo), diabetes (on insulin), hypertension (on beta blocker), CHF (on lasix), and DVT (on Coumadin) – yeah, I know, survival of the fittest! From what I heard, he did have a smile on his face, so at least he had that going for him, which is so amazing to me – if only we could all be like that!
His vitals: T 36.7 RR 18 HR 90 BP 88/60 O2 sat 93% RA; code status: Continue reading
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… 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
Yup, that’s right, we are going to go through the RUSH exam this week. Its “RUSH” WEEK!!!! To all those in SonoSororities and SonoFraternities out there, this week is going to be dedicated to “rush”ing to evaluate the patients in shock, and trying to figure out the cause of it by your handy-dandy bedside US machine – especially when the case is not obvious, but you know you need to “rush” to their bedside….ok, Ill stop “rush”ing
RUSH stands for Rapid US in SHock and written by great friends of mine, namely Phil Perera, Tom Mailhot, D Riley, and Diku Mandavia who coined the terms Pump-Tank-Pipies – with inspiration from an original RUSH protocol by another great friend of mine, Scott Weingart (aka emcrit) who coined the acronym HIMAP (heart, IVC, Morison’s (and other FAST views), Aorta, Pneumothroax (see a great podcast by him here). Both start with the heart, and for good reason – you may find the cause immediately, and you’ll be able to identify if the patient can tolerate fluids. Both also arose from varying research studies by Rose et al. (the UHP protocol) and by Bahner et al (Trinity protocol). Here, we will discuss the 3 sections to evaluate:
The study coming out in Annals of Emergency Medicine in June done by Haydar et al “found point-of-care ultrasonographic data about cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility to be clinically useful in treating adult patients with sepsis” – for those of us who use US regularly to evaluate patients in shock, whether it’s by using the RUSH protocol or evaluating the initial and post-fluid volume status for those we are trying to resuscitate when septic, it’s no big surprise. What is the surprising aspect of this is that 53% of septic patients’ treatment plans had changed due to the findings by ultrasound of cardiac contractility and IVC appearance. Continue reading