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

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:

…..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: 70 yr old fever, hypotensive after root canal, diarrhea & abd pain…”RUSH” +1

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…)

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.

SonoCase: 57 yr old with acute chest pain, light-headed….

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

SonoCase: 62 year old male c/o general weakness… you “RUSH” to his bedside…

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:

SonoCase: 75 year old coming in unresponsive…

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…

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.

SonoCase: 78 yr old, hypotensive, altered…Welcome to “RUSH” week!

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) and Lichtenstein’s FALLS protocol (see thebluntdiessection’s article). Here, we will discuss the 3 sections to evaluate: