From the Division of Critical Care Medicine (Drs Eisen, Janowski, and Shiloh), Department of Medicine, Albert Einstein College of Medicine, Jay B. Langner Critical Care Service, Montefiore Medical Center, Bronx, NY.
Correspondence to: Ariel L. Shiloh, MD, Division of Critical Care Medicine, Montefiore Medical Center and The Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467; e-mail: email@example.com
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A woman in her fifties with recurrent, metastatic renal cell carcinoma, previously treated with a radical nephrectomy and transurethral resection of a bladder tumor, was admitted to the hospital for management of chemotherapy-induced weakness and malaise. The patient was anemic and required RBC transfusion. Worsening hematuria was attributed to a recurrent bladder mass.
On hospital day 3, a rapid response code was activated for sudden unresponsiveness. Upon arrival of the response team, the patient was noted to be pale, diaphoretic, and in acute hypoxic respiratory failure. The patient’s BP was 90/40 mm Hg, and heart rate was alternating between tachycardia and bradycardia. Oxygen saturation on 4 L nasal cannula was 80% to 85%. Response to verbal and noxious stimuli was absent. The patient’s breathing was rapid and labored, and the lungs were clear to auscultation. ECG demonstrated right-sided ST elevations and complete heart block. The patient was promptly intubated and transcutaneous pacing was initiated.
Differential diagnosis included the following: cardiogenic shock due to myocardial infarction, obstructive shock due to pulmonary embolism, obstructive shock due to pericardial tamponade, hypovolemic shock, and hemorrhagic shock. After stabilization of the airway, the intensivist team performed bedside ultrasonography to determine the cause of shock and acute hypoxic respiratory failure (Video 1-4).
Ultrasound used to diagnose obstructive shock due to pulmonary embolism.
In Video 5, the apical four-chamber view demonstrates a severely dilated right ventricle and atrium with right ventricular hypokinesis, highly suggestive of either an acute right ventricular infarct or acute pulmonary embolism. Although it is a limited view, with most of the left side of the heart obscured, the findings are correlated in a subcostal view, seen in Video 6. In addition, the subcostal view rules out the presence of a pericardial effusion and displays a compressed and underfilled left ventricle secondary to right ventricular overload.
Apical four-chamber view demonstrates a severely dilated right ventricle and atrium
Video 7 shows a dilated inferior vena cava (IVC) with massive mobile thrombus in transit to the right atrium. Visualization of thrombus is diagnostic of a VTE or possibly, in the case of metastatic renal cell carcinoma, tumor embolism, as compression examination at the common femoral and popliteal veins did not identify a thrombus. Video 8 demonstrates a fully compressible common femoral vein without evidence of DVT.
Dilated inferior vena cava with massive mobile thrombus in transit to the right atrium
Fully compressible common femoral vein without evidence of DVT
Massive pulmonary embolism was diagnosed based on ultrasound and clinical findings. As a possible lifesaving intervention, an interventional radiologist was consulted for catheter-directed thrombolysis. Systemic thrombolysis was contraindicated in the presence of worsening hematuria. Within minutes, however, the patient became increasingly bradycardic and hypotensive. Dopamine infusion was initiated, and a transvenous pacemaker was placed using ultrasound guidance. Video 9 displays the pacemaker wire positioned at the apex of the right ventricle. Despite appropriate placement and electrical capture on ECG, there was lack of mechanical conduction. Despite maximal efforts at resuscitation, the patient developed refractory pulseless electrical activity and died.
Pacemaker wire positioned at the apex of the right ventricle
Rapid response teams (RRTs) are becoming increasingly popular in hospital systems. A demand on the limited number of ICU beds requires more acute and complex patient care to be delivered on the general wards, outside of the ICU.1 In this case, we demonstrate how using goal-directed ultrasonography (GDU) during a rapid response assists in formulating a diagnosis, focusing therapy, and guiding procedures.
Implementation of the RRT is meant for the early identification and prevention of cardiac arrests. The majority of the “Hs and Ts,” described in advanced cardiac life support as major contributing factors to developing cardiac arrest, can be screened for by the use of GDU.2 The rapid assessment of these factors helps guide therapy in the crucial moments leading up to a cardiac arrest.
A fully collapsed IVC, or marked variability in IVC diameter, in the setting of an effaced and hyperdynamic left ventricle indicates the presence of hypovolemia and the likelihood of fluid responsiveness. Free fluid in the abdomen may indicate acute hemorrhage, especially after trauma and procedures.3,4
Using the “Blue protocol” developed by Lichtenstein and Mezière,5 an accurate diagnosis can be made in 90.5% of cases of acute respiratory failure. Pleural effusions, pulmonary edema, lung collapse, pneumonia, pulmonary embolism, pneumothorax, and exacerbation of reactive airways disease can all be identified by GDU.
Pericardial effusions are readily identified and signs of tamponade, such as right ventricular diastolic collapse and IVC dilation, are best evaluated in the subcostal and apical four-chamber views.6
The absence of lung sliding and the presence of a lung point reliably indicate pneumothorax.5
GDU identifies regional wall-motion abnormalities, septal dynamics, major valve failure, and global cardiac dysfunction that are associated with acute coronary thrombosis.3
A dilated, hypokinetic right ventricle in the setting of a normal thoracic aeration pattern is highly suggestive of VTE. The identification of DVT on compression examination or thrombus in transit is diagnostic of VTE.5
In addition to RRT diagnostics, ultrasound is indispensable for the guidance of lifesaving bedside procedures that include, but are not limited to, central venous catheterization, chest tube placement, and pericardial decompression.
Ease of use, portability, and real-time diagnostics are some of the key features of bedside ultrasound examination. With only moments between life and death, GDU allows for timelier, accurate, and focused management of cardiopulmonary collapse by a RRT.
1. Goal-directed ultrasonography allows for timelier, accurate, and focused management of cardiopulmonary collapse by a RRT.
2. Ultrasound is indispensable for the guidance of lifesaving bedside procedures.
3. In a shock scenario, a dilated and hypokinetic right ventricle is highly indicative of a pulmonary embolism.
4. Thrombus in transit, either in the IVC or the right side of the heart, is diagnostic for a thrombotic event.
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: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
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