Cases

This week is a case of a 29 yo F with known severe pulmonary hypertension. The etiology was thought secondary to cocaine-induced idiopathic pulmonary arterial hypertension. Unfortunately, she sustained a cardiac arrest (you’ll see why when you look at the images). ROSC was obtained and she was transferred to the ICU. Despite maximal medical support of her RV (optimal ventilator management, IV flolan, inhaled nitric oxide, inotropes including milrinone and vasopressin) she had persistent hypotension and worsening renal failure necessitating CRRT. The overnight team decided to trial some small boluses of crystalloid to see if that would help. Have a look at the images below and decide whether or not you would give fluids or recommend something else? If I said the CVP (as measured from the right IJ central line) was 22, what would the estimated RVSP be?

It’s a 78 yo M with unwitnessed syncope, a subsequent tib-fib fracture, who was eventually admitted to the ICU for persistent hypotension and altered LOC that had not been fully elucidated. He had an extensive work up including a negative CTPA, CT head, and ultimately even an angiogram (based on some transient diffuse ST depression and a positive troponin) which showed clean coronary arteries. He eventually stabilized with good supportive care, and the ICU team was now trying to wean him off the ventilator and were aggressively diuresing him. They asked for a POCUS assessment to help guide further volume management. Have a look at the images. What two major findings are most striking? Should the team continue to diurese him or perhaps give some volume back?

This is a 39 yo F post cardiac arrest NYD. She was in the weaning stages of her care and close to extubation, but she became newly febrile with increasing oxygen requirements. Her sputum culture was positive for E. coli. A portable CXR was done which did not show any obvious large consolidations. A POCUS thoracic study was performed. An unusual finding was seen on the left side (shown in the clips below). Also, to orient those who aren't familiar with the WesternSono shorthand here is a legend for the labels: L1 = Left anterior chest wall, L2 = Left anterior axillary line, L3 = Left costophrenic view, and L4 = Left PLAPS (PosteroLateral Alveolar and/or Pleural Syndrome)

This is 54 yo M who presented for an elective surgery. On POD # 0 he became tachycardic with subjective dyspnea and hypotension progressing into a PEA arrest. ROSC was quickly obtained with typical ACLS and he was placed on life support and transferred to the ICU for further management. A CTPA was negative, and his EKG was unremarkable with no evidence of coronary ischemia. On POD # 1 he remained hemodynamically unstable, and given very poor transthoracic windows, the decision was made to perform a TEE. Have a look at the images and Doppler information below. Is there a finding that may explain the etiology of his arrest? What would your recommendation be to the treating team?

This is a 35 yo M PWID who presented with a right septic AC joint, MRSA bacteremia and hypoxic respiratory failure. He was taken to the OR for washout of his AC joint and subsequently transferred to the ICU for post-op management. A post-operative CXR showed some patchy consolidations but no obvious pleural effusions. The POCUS team was subsequently deployed. Interrogation at the costophrenic angle and PLAPS (posteroalveolar and/or pleural syndrome) point on both sides yielded the following images. What do you see and what should the next steps in management be?

A 47 year-old female is admitted to ICU for respiratory failure and sepsis. She has a history of immune suppression and has had a prolonged stay in ICU. She is requiring pressors and the POCUS team was asked to assess cardiac function.  Here are some of her echo images:

A 30-year-old female, presents to the emergency department with acute lower abdominal pain. She is 9 weeks pregnant by dates and has had no formal ultrasound prior to presentation. Her initial vitals are; HR 102, BP 116/70, RR 24, T 36.2 and SpO2 98% on RA. A bedside ultrasound is completed and demonstrates:

A 75 year old male presents to the emergency department with delirium and fever. You use your POCUS skills to look for a possible source of infection in his lungs.

Hi POCUS enthusiasts, We set a new record with >65 participants in last week's case voting. Unfortunately this will be our last COTW/COTG until we are back in action in early April. For all those who haven't signed up for automatic distribution do it now by going to westernsono.ca and filling in your name and email address. This will be the last email reminder! Now let's jump into [...]

Hi POCUS enthusiasts,Thanks again to the more than 20 participants in the online voting for last week's case! For those who have yet to sign up, just go to westernsono.ca and insert your name and email into the text box on the right side of the webpage. Then get ready to flex your POCUS muscles and post your answers/votes. Or click here to access the case directly: https://westernsono.ca/category/cases/ The [...]