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. She arrives, obvious tripod position and wont lay down, working to breathe on NRB, but alert and able to speak in 1-2 words and nod/shake her head to questions. EMS report: history of hypertension, Diabetes mellitus, CHF, COPD not on home O2, drug abuse (most of the time meth or heroin – guess she regulates her ups and downs), and worse shortness of breath over the week but tonight with sudden increased severity – also has paperwork on hand stating there is an increasing pulmonary nodule on her prior chest Xray. Oh, and their blood glucose was 184. She is also complaining of chest pain (basically, I ask her if she has it and she nods while pointing to her mid sternum with an open hand). Vitals were unchanged except we now have a temperature of 36.7 (C) and HR is now 100. The nurses are obtaining the 2nd IV access, hanging a normal saline bolus, and getting the intubation tray. The resident speaks to her about her code status (meaning, “youre working really hard to breathe and we may need to give you medicine to sleep and put a tube in your throat to take over and help you breathe. To intubate you. Is that ok?” – she nods) and listens to her lungs which are poorly heard on the right but coarse otherwise, then her heart whose sounds are poorly heard and distant, seeing that she has bilateral peripheral edema to mid-shin (she shakes her head after being asked if that was new). The unit clerk sees if she has been to our ED before after registration.
Somewhere in there, we perform a RUSH exam – talk about a complicated patient! She could have anything! Intubation equipment is being prepared (considering awake, nasal, and ET intubation), but I’d hate to do that and then have her code on me – as we all know intubation is not a simple risk-free procedure. I’d like some info….Is this cardiogenic shock from an MI ? Is this a PE from this weird lung nodule – maybe cancer and now hypercoagulable? Is this a tension pneumothorax from a popped bleb from her COPD since we cant hear breath sounds on the right? – I’d hate to place an angiocath to find out that it actually wasn’t one. If I intubate her without knowing that she has a tension pTX, she may definitely code. Is this severe CHF exacerbation or maybe flash pulmonary edema on top of it from her drug use? Is there tamponade since her heart sounds are so distant and she had this gradual shortness of breath this week? Should I give her fluids or pressors or both – Id love to know her volume status…. This is what I see:
The PUMP: aka the heart….performing the subxiphoid, parasternal and apical views can be challenging when they are sitting upright, but we try anyway…the parasternal and AP4 views were the successful ones:
Apical 4 chamber view (AP4):
Parasternal Long view (PSL):
ok, so poor contractility, and with a history of CHF, not a big surprise, although we dont have a prior to compare. And look at that effusion! Now we know it’s a left pleural effusion and not a pericardial effusion since the PSL view shows the black fluid travelling behind the LV and behind the descending aorta (a pericardial effusion would travel anterior to the aorta).
The Tank: the volume (IVC eval), the leakiness (pleural effusion, ascites -( FAST scan )- and pulmonary edema -( thoracic US)) and the compromise (pneumothorax -( thoracic US)) are evaluated for and her results are shown below. The IVC was best seen in her right upper quadrant FAST view (with a slight change in angle) to view the longitudinal IVC just distal to the liver as the sunbxiphoid was unable to be obtained with her sitting.
wow, you can really see the dilated IVC, and once again a pleural effusion, this time on the right.
RUQ of FAST:
LUQ of FAST:
So, no intraperitoneal free fluid (although missing the inferior pole of the kidneys on above images), but we do see the bilateral pleural effusions again.
Thoracic US: Right side in 2 out of the 4 quadrants shows:.
Thoracic US: Left side in 3 out of the 4 quadrants:
Thoracic: Pneumothorax evaluation
After seeing the above, it was obvious that she was overloaded (dilated IVC, pleural effusion seen on PSL view as well as above the diaphragm in the right and left upper quadrants of the FAST, as well as the significant B lines bilaterally in multiple sections of the chest – without evidence of tamponade or significant PE causing RV strain or pneumothorax – So, we stopped the fluids and ordered high dose nitroglycerin and lasix after dopamine was on board to stabilize her vitals. She wasnt declining, “stabley unstable” is how my resident called it so we held off on intubation just a bit longer.
The PIPES: even though I doubted it, I still looked to see if she had a AAA or dissection. She was sitting upright, so I could only see the right upper quadrant view of her descending aorta through my FAST scan view where the IVC is shown above and the aorta is shown as a longitudinal structure below it on the screen (see below) and a small area of her suprarenal abdominal aorta. For the same reason, I could only asses her popliteal veins to look for complete compression. I decided to do that anyway since her medical history was so complicated that maybe a PE not causing RV strain could still be the cause (ah, heck, I just wanted to make myself feel better).
Aorta: right upper quadrant view of descending aorta
DVT: popliteal veins only (bilateral showed the same thing as below)
Amazing what high dose nitroglycerin and lasix does in such a short amount of time, especially with a foley which filled up quickly. She rapidly improved, able to speak to us better, said that she took a hit of heroin right before she came and had been noncompliant with her medication that she uses for…. well, everything. Intubation was avoided, ICU stay was avoided, and she stayed stable now off drips, and, 10 hours later, got her telemetry bed – dont get me started on the delay. Another reason why everyone should avoid heroin… but can still use the RUSH.
For a review of the RUSH technique and to go to another case, go here.
Do you give nitro with hypotension? Did her BP improve with nitro?
Thanks for the question – we gave dopamine and stabilized her BP then started the high dose nitro drip. Her entire respiratory status improved with nitro and lasix as she had lots of fluid removed.
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