Critical Care Ultrasound Vignettes from UltraSoundHD

The three ultrasound videos that  follow are all from the UltrasoundHD Channel which has 55 us videos.
Pt with hypotension post cardiac arrest on a ventilator.
Physical exam unrevealing
Ultrasound scan W/U could include:
cardioscan (subcostal +/- parasternal long, apical 4 chamber)
FAST scan (if bleeding suspected)
Scan for DVT (if PE suspected because you will find a DVT in 50% of pts with PE)
Liver/Gall Bladder Scan (if hypotension thought secondary to fever or sepsis [acute cholecystitis is a cause of sepsis in ICU pt])
His pneumoscan revealed pneumothorax before CXR could be obtained and chest tube placed and pt improved.
62 yo w pneumonia in ICU for 3 days but was doing well and was to be transferred out later that day.
He suddenly dropped his O2 sats and became diaphoretic and SOB.His BP is unchanged at 130/86.
Vitals:         130/86         108         22          Afebrile         86%
Physical exam unrevealing.
He did not appear to need endotracheal intubation but was changed from two liters of nasal cannula to 40% ventimask. And his O2 sats went up.
CXR, EKG, ABGs, CBC, Chem Panel, INR, PTT was ordered.
The plan was: If CXR was negative, then the patient would be anticoagulated for a possible PE or ACS. And a CT angio was to be ordered if the CXR was negative.
A focused bedside ultrasound was performed while awaiting the above tests.
Cardiac US to look for segmental wall motion abnormalities of ACS.
FAST scan to look for intraabdominal bleeding
DVT scan of both of his legs to see if he had a deep vein thrombosis which can be seen in 50% of  people who have a pulmonary embolus.
Note that these scans were performed very rapidly before even the CXR could be obtained.
The four chamber apical view of the patient revealed that the right ventricle as the same size as the left ventricle (it should have been 2/3 or less of the LV). If we freeze the image and measure RV and LV, the RV is actually bigger (abnormal).
Also noted on the apical four chamber is apical hypokinesis.
So the findings are: apical hypokinesis and RV enlargement.
The EKG shows NSR with IVCD and non-specific ST-T wave changes.
The FAST scan was normal.
But the DVT scan of the left leg was positive for DVT.
So the bottom line of Vignette 2:
Apical hypokinesis (with no increase in troponin [but the troponin had been drawn immediately and repeat later most likely will be increased–and remember that a large PE can cause elevated troponin and elevated BNP as EMCrit has stated]) from ischemia and RV enlargement.
The apical hypokinesis is probably from ischemia. It may be old as in an old infarction. Or it may be new, as with ischemia.
But more important, actually, is that there is an enlarged right ventricle. And this is commonly seen with pulmonary embolism. So it is hard to tell from this whether the changes of the apex are old or new.
So the presumptive diagnosis for the acute dyspnea is pulmonary embolus with secondary myocardial ischemia from the PE [I think that is what the author is saying].
A CTA for PE was avoided and this was beneficial to the patient has he had DM and renal insufficiency.
64 yo on a vent who has become very SOB. You are told by the resident that the patient’s CXR reveals a pneumothorax presumably from the vent.
Right side of CXR shows a large pneumo which could account for his SOB.
A physical exam is performed as US is never a replacement for physical exam.
If there is lung sliding, then there is no pneumothorax. Also an M-mode without pneumothorax will show the sky beach ocean pattern.
The presence of B-lines (comet tail artifacts) also suggests that there is no pneumothorax.
When a pneumothorax is present there is no lung  sliding and M-mode will show the barcode pattern.
The CXR showed a line on the right and radiology did read the xray correctly as an artifact from skin fold but half an hour after
the ICU resident read it as a pneumothorax and a half an hour later the radiologist called artifact secondary to probable skin fold–patient was chachectic so not a skin fold rather a folded cloth under the patient). Magnification revealed vesssels beyond the line.
But an immediate pneumoscan revealed no pneumothorax and a chest tube which would have been placed (because of the lack of timeliness of the radiologist’s) was not placed.
So if it is not due to a tension pneumo, why is the patient so short of breath?
And therefore further ultrasound exam was performed.
The doctors were unsure of pt’s fluid status.
  • Due to language barrier, pt would not open his mouth for exam.
  • Renal insufficiency made urine output unreliable.
  • The patient had a mild hypoalbuminemia.
  • There was no JVD but JVD is seen only in about 20% of ICU patients [presumably, he means who are fluid overloaded–otherwise this statement’s meaning is unclear to me.
  • BP was normal and without orthostasis.
Cardiac ultrasound revealed a hyperdynamic.
There is essentially total obliteration of the LV cavity on parasternal long axis as the heart is beating. This is a hydynamic heart and hyperdynamic hearts are commonly seen with dehydration.
Sonographic exam of the IVC revealed significant intravascular dehydration.
An IVC diameter  of less than 1.5 cm especially with collapse of > 50% is suggestive of volume depletion esp with a hyperdynamic heart.
The patient was given 1.5 liters of saline and his symptoms resolved.
Bottom Line of Vignette 3
  • Never rush your readings x-rays or other tests.
  • Ultrasound is more sensisitive and specific than conventional x-rays in diagnosing a pneumothorax in supine patients (even when the x-rays are correctly interrupted).
  • Ultrasound cannot be used to replace a good physical exam but can be used to enhance it.
You are called to the bedside of a 59 y/o man with sepsis who is now hypotensive. He is awake but is confused.
96/52     120     22      38.1     90%
Add Picture 1 from UltrasoundHD Vignette 4 Folder
As part of your exam, you perform a bedside ultrasound exam.
A parasternal long axis is performed and shows pericardial effusion and what in a heart without pericardial effusion would be diagnosed as hyperdynamic heart.
A short axis view through the base shows pericardial effusion and RV collapse! And a huge pericardial effusion.
An apical 4 chamber shows pericardial effusion and RV collapse!
The 4th view is a subcostal 4 chamber view which shows pericardial effusion and RV collapse.
So, what is the diagnosis?
Cardiac Tamponade!
Dr. Rosen analyzes (image 1) the parasternal long axis and in addition to my findings above (which are correct) he notes that there is poor septal wall motion and poor LV filling (from the pericardial tamponade [not from hyperdynamic heart which is from volume depletion).
Bottom Line of Vignette 4
Pericardial tamponade can present in many different fashions, one of them being hypotension.
Beck’s triad of muffled heart sounds, JVD, and hypotension presents in a minority of patients.
Cardiac ultrasonography, as with all ultrasound, should be performed with multiple views. And we could see from some views that the pericardial tamponade was much larger than from other views.
And cardiac ultrasound is an excellent means of diagnosing cardiac tamponade.


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