This was a case of an 80 yo M, previously healthy, with no known significant previous medical history. He presented to the ED with acute decreased level of consciousness. The leading concern was acute spontaneous ICH. He was intubated and taken for a CT Head which surprisingly was completely normal. He was subsequently transferred to the ICU with the diagnosis of altered LOC NYD. A POCUS study was performed, and several cardiac clips are shown below. What do you think? Does this give a potential clue to what could be going on?
This is 65 yo M who presented with acute hypotension, hypoxia, and worsening AKI in the setting of known severe pulmonary hypertension secondary to a previous PE (CTEPH). He was admitted to the ICU for consideration of CRRT and IV flolan. A few days into his admission, the team asked for a POCUS cardiac assessment to reassess the status of his RV. Have a look the images below. Specifically, what do you think about the tricuspid regurgitation and estimated RVSP?
This is a 74yo F with a past medical history significant for ESRD and severe PVD who was transferred to the ICU overnight with presumed septic shock thought to be related to left foot osteomyelitis. She had presented to the ED with refractory hypotension and altered LOC necessitating intubation and high dose vasopressors. The POCUS team went to do a focused cardiac exam, primarily to see if there was a cardiogenic component to his shock. The following TTE images were taken and the decision was made to perform a point-of-care TEE. What do you think is going on?
This is a 70yo F with a recent diagnosis of left sided lung cancer. She presented with hemoptysis and was subsequently admitted to the ICU for monitoring. There she was found to be tachycardic at 120bpm and had reduced urine output. The patient had no known cardiac history and no previous echocardiogram on file. The POCUS team performed a focused echocardiogram, given that she was a newly admitted patient with ongoing tachycardia.
This week's case is a 67-year old woman who presented for an outpatient EGD. Post-procedurally she became hypoxic, so was brought to the ICU for monitoring and NIPPV. She was initially hemodynamically stable; however, over the next 6 hours she became profoundly hypotensive requiring very high doses of multiple vasoactive agents. She had a PMHx significant for severe COPD and HFpEF, with an Echo from earlier this year showing an EF of 50%. Below are her the clips taken upon arrival of the POCUS team the next morning. What do you think is causing her shock based on these images? You might want to make yourself comfortable, cause this week's case is a doozy and has a lot to unpack. *Note: given her marked hyperinflation she had no obtainable traditional parasternal or apical windows, so all views were obtained from a modified subxiphoid position (hence the unconventional axis). These scans are a good lesson, however, that you can still get lots of important information even when your views aren't perfect!
85 yo M polytrauma from a high-speed MVC. Now recovering in the ICU, still intubated, but over the last few days has had worsening oliguric AKI and is now on 10mcg/min of NE. The POCUS team was asked to perform a “volume status” assessment. This is one of the most common requests we get. Below is a representative look at a typical set of images we try to acquire to help answer the million-dollar question of whether a patient would benefit from fluids. Have a look at the images below (which, be forewarned, are quite Doppler heavy) and see what you think!