Emergency Pericardiocentesis post-arrest (Part 1). #FOAMed, #FOAMus, #FOAMer

So a few nights ago I got pulled out of slumber to rush to the ER for an elderly patient who had arrested in hospital shortly after having been brought in for chest pain. The sharp ER doc had diagnosed a tamponade on a presumed aortic dissection, managed to get a needle in, aspirated some fluid and managed to get ROSC.

So when I got there we had a patient post-ROSC in rapid atrial fibrillation with a thready but palpable pulse. POCUS showed a large pericardial effusion with minimal LV filling. So here is what we did:

With the catheter in, we were able to drain. Note a couple of POCUS teaching points, always make sure to (1) visualize your guidewire in the right space, and (2) second, when using a dilator, you can note the disappearance of the proximal part of the guidewire as it is covered by the dilator. This tells you you have adequately dilated into the target structure – pericardium in this case, because it is possible (personal experience) to advance a dilator fairly deep, but not go through a perhaps fibrotic pericardium, and then result in pigtail mis-placement just outside of the target.

In part 2 you can also see the aspiration of the effusion and improved LV filling. The patient’s BP instantly rose to 140’s systolic.

More case details and POCUS teaching points to come in part 2.

cheers,

ps – a sterile probe cover was unavailable immediately in the ER. By the time it showed up the pigtail was in. We didn’t feel we could wait. We doused it in alcohol.

Philippe

 

Bedside Ultrasound Case: Look Left and Right! #FOAMed, #FOAMus

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!

 

Thanks FOAM!

 

cheers

 

Philippe

 

 

A Witnessed Arrest: Advanced Bedside Ultrasound. #FOAMed, #FOAMcc, #FOAMus

So I was taking over the ICU in the evening, and as I walked in I hear that an arrest had happened and she was now being wheeled out of the ICU to radiology for a CT head and CT angio. So I didn’t get to do a bedside exam.

The story was that an 84 year old woman who had been admitted for atrial arrhythmia had been noted to have different blood pressure in the upper extremities, and the concerned family had urged to hospitalist to seek additional opinions. At the very moment when she was being examined by but the daytime ICU doc and a cardiologist, she suddenly deteriorated. They were actually in the process of bedside ultrasound, which had been normal aside from a small pericardial effusion, when she became unresponsive, seemed to have some lateralizing signs, became bradycardia and arrested. They got ROSC with an epic within a couple of minutes.

The feeling was that, having been started on one of those NOACs (Eliquis), she had bled and arrested by neurocardiac axis. Definitely reasonable, but given the BP discrepancy, ruling out aortic dissection was also a must.

So here is the scan:

A quick glance reveals an ascending aortic aneurysm with what appears to be a dissection and a visible flap. The CT of the head was normal.  A closer look seems to reveal that the dissection extends into the brachiocephalic trunk.  My colleague discussed with the radiologist who repeatedly told him it was a type A but wouldn’t say anything more (don’t ask…). Just as a reminder, here is the current classification:

aortic dissection class

So in discussion with the family, there was obviously concern about the possible stroke (an early normal CT obviously does not rule out an ischemic infarct) and given that a palpable pulse does not exclude dissection, bedside ultrasound was the next step (also because the radiologist had not clearly pronounced himself on the scan – in all fairness he may have just done a preliminary reading – so here is what we see, with the carotid being in the lower right area of the flow box, and part of the jugular in the left upper.

As a comparison, here is the left side (normal – but inverted – jugular rt and carotid lt).

Clearly, most of the right carotid lumen is actually false lumen of the dissection, with only a small crescentic lumen between 3 and 6 o’clock. Not good.

Here are the basic cardiac views:

subxiphoid

parasternal long axis

 

We can see a small pericardial effusion which looks textured – likely blood, and essentially normal function.  Now here is a right-sided parasternal view, showing the dissected aneurysm, including the dissected intimal flap:

Now this isn’t a routine view, and honestly I did it after having seen the scan where one can see that the aneurysm abuts the chest wall, which would make it ultrasoundable, and i can’t really say I would have done it without that knowledge. But now I would, if a similar case would present itself. Very insensitive but quite specific.

So I thought this was an interesting case to show, as a rapidly developing clinical picture, and from the point of view of bedside ultrasound, it displays the usefulness of carotid imaging and alternate views – and how simple it is to do.  Unfortunately at her age and given state she was not deemed a surgical candidate and passed away the next day.

 

thanks for reading!

…to sharpen up your resuscitation and ultrasound skills, don’t forget to come to CCUS 2015, may 1-3 in Montreal, Canada!  Register at http://www.ccusinstitute.org and for more details,http://wp.me/p1avUV-aU

 

Philippe