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Case #6 – ED TEE for Cardiac Arrest

27 Jan

In this case a sudden deterioration in the emergency department prompts a TTE which shows some concerning physiology.  It is not until the TEE is inserted, however, that the culprit disease can be identified.

*Images courtesy of Dr. Drew Thompson, Division of EM, Western University

Case Highlights:

*TEE in the ED is valuable for critically ill patients

*TEE has advanced diagnostic potential, including the identification of aortic dissection in a rare number of cases

*TEE has value in cardiac arrest in particular for its ability to provide all the benefits of echocardiography (identification of reversible causes, prognostication, subjective and objective evaluation of CPR quality) without any need to interrupt chest compressions

Case #5: What a difference a day makes

17 Dec

In this case you will see 2 echos from the same patient only 1 day apart.  The patient had raging septic shock from a skin source and was requiring significant hemodynamic support.  You can appreciate the cardiac dysfunction from a 2D point of view but also from a quantitative point of view.  The next day – you will see significant changes, now off inotropes (epinephrine, milrinone and norepinephrine).

*Images courtesy of Dr. Vincent Lau, critical care fellow, Western University

Case Highlights:

*Septic cardiomyopathy is a common cause of LV and/or RV dysfunction in the context of severe sepsis or septic shock

*Point-of-care echo can be used repeatedly to recognize  often rapid changes in cardiac function that occur during septic illness

*Quantitative stroke volume determination (using VTI from the LVOT) can additionally support your findings and guide management

For a similar case on septic cardiomyopathy, check out CHEST ultrasound corner here.

Case # 4: Post-op shortness of breath

30 Oct

By Rob Leeper, MD, FRCSC

The Critical Care Outreach Team is called to asses a 64 year old male on the thoracic surgery floor complaining of increasing shortness of breath and hypotension. He is status post left upper lobectomy for non small cell lung cancer 1 year ago.  He has been re-admitted for workup of a possible recurrence in his mediastinal nodes.

In the 24 hours prior to CCOT arrival he had become progressively acidotic and hypotensive.  This was presumed to be on the basis of sepsis and appropriate treatments had been instituted.  Despite this the patient remained hypotensive with BP sitting 90’s/50’s.  His gases and clinical state worsened and he was taken to the ICU for further evaluation and monitoring.


As is routine for patients admitted to our ICU’s with circulatory failure, a point of care echocardiogram was performed on arrival to the ICU:

Subcostal 4 Chamber

 

Parasternal Short Axis

 

Apical 4 Chamber

 

What is your impression of the images?  Is there any significant abnormalities seen?  Click HERE for the answers and discussion and to learn the outcome of the case.

Case # 3: Leg cramps

28 Aug

A 55 year old male presents to the emergency department with a 5 day history of increasing shortness of breath on exertion and recent leg “cramps”.  In the 24 hours prior to presentation he had noticed increasing back pain and hyperventilation, with one episode of hemoptysis.  The patient was tachycardic, transiently (30 minutes) hypotensive and had an oxygen saturation of 90% on non-rebreather mask with marked dyspnea.

A point of care echocardiogram was performed and demonstrated the following:

Parasternal Long Axis

 

Parasternal Short Axis

 

Inferior Vena Cava

 

What is your impression of the images?  Is there any significant abnormalities seen?  Click HERE  for the answers and discussion and to learn the outcome of the case.

Case # 2: A pain in the thigh

21 Apr

A 28 year old male presents with a painful right thigh. On exam you find a indurated, red area overlying the inguinal region of his right leg. He says it has been grumbling for some time with a few courses of antibiotics that have now stopped containing it. It is clearly infected. You are uncertain however, what the yield of an I and D will be. A point of care ultrasound is undertaken to assess the area:

You then increase the depth somewhat to survey the surrounding structures:

What is your impression of the images? What are your next actions? Any concerns with I&D? Click HERE to review the answers to these questions and further discussion on ultrasound for skin and soft tissue infections.