So I get a patient in the ED who had chest pain and a decreased LOC, vomited and got intubated. I see this elderly (88 yrs old) gentleman a couple of hours after presentation, after basic management including some plavix and heparin for a mildly elevated troponin.
Of course, by now you all realize that a rapid CUSE (Critical UltraSound Examination) is what I start with, after an ultrabasic history.
So my first couple of views show a more-or-less normal IVC, and here is the parasternal long axis:
Anything exciting here? Not really, nothing to hang your hat on at a glance.
Ok, so thanks to FOAM, I recently decided to add the right parasternal view to my regular exam, both to look for lung sliding (I admit I sometimes skip this when not specifically looking for pneumothorax) but also to possibly see some right sided pericardial abnormalities, etc… Here is what I see:
Hmm… A large, vascular structure that seems to have two lumens… a flap? Back to the patient exam, and the left toe is upgoing and seems more flaccid in the left upper extremity…
Lets creep up the vascular path to the neck vessels:
Here, we can clearly see that most of the carotid lumen (lower right) doesn’t have any flow. That’s suboptimal. In fact, only a small crescent of flow between 3 and 6 o’clock is seen.
Here is the CT:
So here we can clearly see the dissected ascending aortic aneurysm that extends into the right carotid artery.
Due to advanced age and dismal overall prognosis, support was discontinued after discussion with the family.
I thought this would be a great case to share due to the fact that it could have been an initial bedside diagnosis, but I have to say I consider it fortuitous that I happened to look right, then up – which I easily could not have done. Not that it made any difference in this case, but on the next one, it just might!
[…] right parasternal view to your echo repertoire- it can be helpful, as Phillipe Rola demonstrates in this case. (I wonder what a suprasternal would have showed?) […]
Putting focus right back to the thoracic aorta! Great teaching-point never to miss colorflow mode in the carotids even though flap is not visualized. Depending on patient physiology, COPD etc, alternate views are also important to know about.1.) Parasternal left, 2.) Parasternal left high, one intercostals up, gives a good 5-7cm of the ascending, 3.) parasternal left high high, parasternal right high, with pointer to the left of the neck for the arch, 4.) Suprasternal with pointer to the left of the neck for arch. For optimal image in the last view put the patient supine with a rolled up towel behind the scapulae (hyperextended neck) head leaning to the right, relaxed sternocleidomastoid muscle and proper amounts of gel. Make it a routine, have a nurse help with the prepping, and 2 minutes later you’re done 🙂 @heartdynamic