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: 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.

SonoCase: 60 yr old male, lethargic, respiratory distress, shock – “RUSH” to bedside

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

SonoCase: 45 yr old female acute respiratory distress…. RUSH, part deux

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

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