So I’m walking to the ED to reassess a COPD’er that was on BiPAP, and one of the ED docs sees me in passing and says – “I might have a case for you, she’s on her 3rd litre and still a bit hypotensive…I’ll let you know.”  So I re-route and decide to take a look right away, because I’m never fond of shock NYD.

So here is this woman in her 50’s, BP is 93/67, RR 22 and moderately dyspneic. She has been increasingly so for a few days without infectious symptoms. The X-ray is clear and her labs unremarkable aside from a lactate at 3.3 mmol/l.  She is moderately overweight but quite active. Non=smoker without any cardiorespiratory known illness and on no medications.

Here is what we see on ultrasound-enchanced physical examination:

So, what do you see?

In the first clip, we see a large, dilated IVC with little variation – despite the dyspnea, making it a more significant finding – according to the Effort-Variation Index (http://wp.me/p1avUV-9k).   This automatically implies there will be some pathology (unless iatrogenically very volume loaded) to be found downstream.

In the second clip, you have a hyperdynamic and underfilled LV and a dilated, poorly contractile RV.  In the absence of cardiopulmonary disease and in an active patient, this is highly suggestive of an acute process, namely pulmonary embolism.

On further questioning she had done a new yoga stretching class as a possible endothelial-damaging process.

So what did I do? Get a STAT angioscan:

 

What would you do next?

 

I’ll tell you what I did tomorrow, and hopefully have some good bloody arguments!

 

PS for awesome talks by amazing speakers, don’t forget to register for CCUS 2015!!! For more info: http://wp.me/p1avUV-aU and register at www.ccusinstitute.org!

 

cheers

 

Philippe