Case Presentation & Conclusion
Case Presentation & Conclusion
Paramedics bring into the ED an elderly man who is complaining of rightsided chest and abdominal pain. Earlier this morning, a friend had arrived at the patient’s home and found him on the floor at the bottom of the stairs. The patient is in pain, somewhat altered, and unable to provide further details about what happened. After numerous attempts, the paramedics were only able to place a 22-gauge peripheral line. On examination, his blood pressure is 98/55 mm Hg, heart rate is 118 beats per minute, respiratory rate is 32 breaths per minute, oxygen saturation is 94% on a nonrebreather, and temperature is 36.0°C (96.8°F). His Glasgow Coma Scale score is 12 (eyes 3, verbal 4, motor 5). Given the unclear events surrounding his presentation and the concern for trauma, the patient is boarded and collared. His chest is stable but tender, and because of noise in the resuscitation room, you have difficulty auscultating breath sounds. The abdominal examination is notable for marked tenderness over the right upper quadrant and right flank, with some guarding. There is also mild asymmetric swelling of his right lower extremity. The patient is critically ill, his history is limited, and at this point the differential is quite broad. You consider the possibility of a syncopal episode followed by a fall, with a closed head injury, blunt thoracic trauma, and blunt abdominal trauma. His hypotension could be secondary to hypovolemia (dehydration or blood loss due to a ruptured aortic aneurysm), heart failure (left- or right-sided dysfunction), cardiac tamponade, tension pneumothorax, or sepsis. Your ED recently purchased an ultrasound machine, you wonder whether bedside ultrasound can help narrow the differential and guide your resuscitation. You call over one of your new faculty members who just finished resident training; a fortunate decision for both you and the patient.
Having recruited your young colleague, an E-FAST examination is performed, and it is noted that the patient has free fluid in Morison’s pouch. There is no fluid in the left upper quadrant, but fluid is present in the pelvis. Your interrogation of the right hemidiaphragm reveals a small-to-moderate amount of fluid above the diaphragm, consistent with a hemothorax. Your colleague helps you scan multiple rib interspaces over the anterior chest, revealing lung sliding on both the left and the right, consistent with no large pneumothorax. The subxiphoid view of the heart is somewhat limited, but no pericardial effusion is evident. Given the limited subxiphoid view, your colleague then helps you obtain a parasternal long-axis view of the heart, which confirms no pericardial effusion but is notable for severely depressed LV function and what appears to be a dilated LV. You then scan the patient’s aorta and see no aneurysm. Your colleague then helps you interrogate the inferior vena cava, and you find it to be flat and with near complete collapse on inspiration. Integrating these ultrasound findings into the overall clinical picture, you surmise that the patient may have had a syncopal event from cardiomyopathy or dysrhythmia. In terms of the patient’s hypotension, you rule out cardiac tamponade, tension pneumothorax, and a ruptured aortic aneurysm and conclude that it is most likely due to solid organ injury, intraperitoneal bleeding, and depressed LV function. Despite numerous attempts, the nursing staff is unable to place a second peripheral IV line, and you use the ultrasound machine to place a femoral introducer sheath on your first attempt. You ask for uncrossmatched blood to be made available and prepare the patient for transport to the operating room. Later in the week at your group meeting, you reflect on this case and consider how BUS helped you narrow your differential, provide time-sensitive physiologic information, guide your resuscitation, and perform an invasive procedure. You are excited to hear about the implementation of an ultrasound program, glad to know that there is literature supporting the use of ultrasound, and eager to learn more emergency ultrasound.
James Q. Hwang; Heidi Harbison Kimberly; Andrew S. Liteplo; Dana Sajed
March 2, 2011