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Postgraduate Education Corner: Ultrasound Corner |

ShockShock: A Case of Mistaken Identity: A Case of Mistaken Identity FREE TO VIEW

Seth J. Koenig, MD, FCCP; Mangala Narasimhan, MD, FCCP; Paul H. Mayo, MD, FCCP
Author and Funding Information

From the Division of Pulmonary, Critical Care and Sleep Medicine, Hofstra North Shore Long Island Jewish Medical Center, New Hyde Park, NY.

Correspondence to: Seth J. Koenig, MD, FCCP, Division of Pulmonary, Critical Care and Sleep Medicine, Hofstra North Shore Long Island Jewish Medical Center, 410 Lakeville Rd, Ste 107, New Hyde Park, NY 11040; e-mail: Skoenig@nshs.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(1):e1-e3. doi:10.1378/chest.12-2878
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Published online

A 66-year-old woman had a brief syncopal episode after standing up from the toilet. She awoke in seconds and noted no chest pain or shortness of breath. On presentation to the ED, she had a BP of 90/60 mm Hg, a regular heart rate of 115 beats/min, temperature of 37.2°C, and a respiratory rate of 26 breaths/min. Her oxygen saturation on 4 L nasal cannula was 91%. The physical examination was otherwise unremarkable. Her chest radiograph was clear, and the ECG showed sinus tachycardia without other abnormality. Laboratory values were as follows: WBC count, 12.7 K/μL; lactate, 3.4 mmol/L; and creatinine, 2.2 mg/dL; urinalysis results were 25 WBC per high-powered field. She was given antibiotics for presumed septic shock with a urinary tract infection, and over the next few hours, per sepsis bundle protocol, she was given a total of 3 L of normal saline. The patient remained hypotensive. Norepinephrine was started at 0.5 μg/kg/min while fluid resuscitation with normal saline was continued. The patient was admitted to the medical ICU with a diagnosis of septic shock. The intensivist performed an immediate bedside ultrasound examination to diagnose and guide management of her hypotension and hypoxemia (Videos 1-3).

Videos 1-3 bedside ultrasound at presentation

Based on the interpretation of these videos and the patient’s clinical history and physical exam, what would be the next area to examine with ultrasonography?
Watch Video 4 for suggested next steps.

Video 4 follow up area to examine with ultrasonography

Answer
The next area to examine with ultrasound would be the lower extremities, which revealed a right popliteal deep venous thrombosis. Massive pulmonary embolism was diagnosed evidenced by the dilated hypocontractile right ventricle and right popliteal deep venous thrombosis.

Video 5 (discussion video) presents further explanation.

Video 5 discussion video

Video 1 is the apical four-chamber view that shows a severely dilated right ventricle (RV) without increased RV wall thickness and McConnell’s sign.1 McConnell’s sign is an echocardiographic finding that may occur in patients with acute pulmonary embolism (PE). There is a distinct regional pattern of RV dysfunction, with akinesia of the mid-free wall that spares the RV apex. This type of regional wall motion abnormality is also known as apical hinging and is highly suggestive of PE. While McConnell’s sign is specific, it has low sensitivity; most patients with a hemodynamically significant pulmonary embolism will have a dilated, hypokinetic RV.2

Video 2 is a parasternal short axis view that shows a dilated RV with bowing of the interventricular septum. This bowing causes the left ventricle to assume a D-shape. As the septal abnormality is present in both systole and diastole, it indicates both volume and pressure overload of the RV. Because of pericardial constraint, left ventricular (LV) cavity size is reduced by the size of the RV cavity with concomitant impairment of LV filling. This results in a decrease in LV stroke volume.

Video 3 shows A-lines with lung sliding that were present bilaterally. This indicates normal aeration pattern of the lung. Lung sliding with a predominate A-line pattern throughout all lung fields indicates with high sensitivity and specificity a pulmonary artery occlusion pressure of <18 mm Hg.3 Alveolar consolidation or a significant pleural effusion that would cause this patient’s tachypnea and hypoxemia was ruled out with bedside thoracic ultrasonography.4

Cardiopulmonary failure in conjunction with a dilated, hypokinetic RV and normal ultrasound findings on thoracic exam is highly suggestive of thromboembolic disease. A venous compression study of the lower extremity is the next ultrasound study of choice. A thrombus was identified in the right popliteal vein, as demonstrated in Video 4. The vessel was not fully compressible, and there was visible clot. Intensivists can perform accurate bedside deep venous thrombosis studies.5

In the ED, this patient was initially treated for distributive shock secondary to sepsis from a presumed urinary tract infection. The intensivists performed a goal-directed echocardiogram, thoracic ultrasonography, and a lower extremity compression study. The results indicated a high probability for the diagnosis of pulmonary embolism. Because of significant renal dysfunction, chest CT scan with contrast was contraindicated. Lung perfusion scan was not immediately available. Over the next few hours, the patient’s cardiopulmonary function continued to deteriorate so tissue plasminogen activator was given, with prompt improvement in hemodynamic status. The patient was weaned off of norepinephrine, her tachycardia resolved, and her oxygen saturation improved. These case videos demonstrate the unexpected finding of a dilated, hypocontractile RV with evidence of significant RV volume and pressure overload in a patient with refractory shock state. The initial diagnosis of distributive shock from a urinary tract infection resulted in treatment with antibiotics and aggressive volume resuscitation. Failure to recognize the etiology of this patient’s shock state at presentation led to the wrong therapy. The appropriate therapy in this patient was to relieve the obstruction by thrombolysis.

As demonstrated in this case, goal-directed bedside echocardiography permits the intensivist to rapidly assess the patient with hemodynamic failure. The examination allows the clinician to categorize the cause of the shock state and to immediately develop an effective management strategy at the patient’s bedside. There is no time delay in performance or interpretation of the examination. In this case the management was completely changed by the information gained by bedside ultrasonography. Goal-directed echocardiography and general critical care ultrasound is easy to learn and can be performed accurately by intensivists.6 This imaging modality should be regarded as routine extension of the physical examination.

  • 1. Critical care ultrasonography performed by the treating intensivist can quickly and accurately categorize shock states in most critically ill patients.7 This aids in therapeutic decision-making regarding choice of vasopressor, inotrope, and volume infusion.

  • 2. RV enlargement and dysfunction may be acute, acute on chronic, or chronic in nature. Clinical history, the thickness of the RV free wall (a thick free wall suggests chronic elevations in RV afterload), and lower extremity compression ultrasonography aid in diagnosis. While McConnell’s sign is a specific finding in pulmonary embolus, acute RV infarction must be considered in the differential diagnosis.

  • 3. The diagnosis of deep venous thrombosis is accurately established with compression ultrasonography alone. Color and spectral Doppler, a standard part of formal examination of the lower extremities performed by the radiology department, is not necessary.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: Patient consent was waived due to the unavailability of the patient or legal guardian.

Additional information: To analyze this case with the videos, see the online version of this article.

McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469-473. [CrossRef] [PubMed]
 
Grifoni S, Olivotto I, Cecchini P, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101(24):2817-2822. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA, Lagoueyte JF, Biderman P, Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest. 2009;136(4):1014-1020. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011;139(3):538-542. [CrossRef] [PubMed]
 
Vignon P, Mücke F, Bellec F, et al. Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents. Crit Care Med. 2011;39(4):636-642. [CrossRef] [PubMed]
 
Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060. [CrossRef] [PubMed]
 

Figures

Tables

Videos 1-3 bedside ultrasound at presentation

Video 4 follow up area to examine with ultrasonography

Video 5 discussion video

References

McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469-473. [CrossRef] [PubMed]
 
Grifoni S, Olivotto I, Cecchini P, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101(24):2817-2822. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA, Lagoueyte JF, Biderman P, Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest. 2009;136(4):1014-1020. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011;139(3):538-542. [CrossRef] [PubMed]
 
Vignon P, Mücke F, Bellec F, et al. Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents. Crit Care Med. 2011;39(4):636-642. [CrossRef] [PubMed]
 
Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060. [CrossRef] [PubMed]
 
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