POCUS in a Condition A

This week’s case comes from Drs. Arshed and Mayr.

This is a 69 yo M, admitted for cabgx4, who’s post-operative course was complicated by heart failure (ef 30%) and new onset atrial fibrillation/flutter with RVR. Patient was started on amiodarone, digoxin and lopressor, and eventually converted to sinus. He was eventually transferred to the step-down unit. The next day a condition A was called. Nurse reported noticing the patient Brady’d down and went into asystole. CPR was started right away and Rosc achieved in 7 mins. Patient transferred back to ICU, placed on vent and found to be persistently hypoxemic, hypotensive, bradycardic with Pip 35 Pplat 32. Good lung sounds noted b/l. POCUS of the lungs was performed by the team with the following clips obtained:

Discussion questions:

1. What probe is being used?

2. What is your interpretation?

3. How/ should POCUS potentially guide your next steps (management, further evaluation, etc)?

4. How confident would you be to act (base don your reply to #3), based on these POCUS clips?

PLEASE post your thoughts & comments to the blog. I will be posting the “answers” in 1 week, on 4/16/18.

-Christopher

 

Comments (3)

schottck@upmc.edu
says:

Hey everyone!

Thanks for the comments and discussions for this post. Below are MY personal thoughts/answers, though there can certainly be some discussion and practice patterns that defer, particularly in regards to question points # 3 & 4:

1. What probe is being used?- Phased Array

2. What is your interpretation?- There is a lung point in the center of the image (highlighted on new clip I added with an arrow pointing it out)

3. How/ should POCUS potentially guide your next steps (management, further evaluation, etc)?- Based on the case provided, I would have a VERY high suspicion for a pneumothorax, potentially a tension pneumothorax, particularly in the setting of hypoxia and an arrest.

4. How confident would you be to act (based on your reply to #3), based on these POCUS clips? - The Lung Point is VERY specific (close to 100%) for a pneumothorax, vs simply noting lack of sliding, so this would make be very concerned for a (tension) PTX and would (personally) feel confident placing an emergent chest tube.

Thank you, Drs. Arshed and Mayr for this case!

-Christopher

aijazihm@upmc.edu
says:

1. Pie Shaped image = phased arrray probe

2/3. Not sure of diagnosis here. hard to say with just the one clip. Clinically a tension ptx would explain an acute decompensation, but pt has bilateral breath sounds. The POCUS has a some missing lung sliding in the middle, looks like pleura is adherent and there is thick hyperintense area. I would consider pna vs clot, with ards/hypoxia being main cause of arrest.

I would however continue to evaluate for ptx with M-Mode, different views, maybe linear probe, etc.

4. not as sure about a diagnosis as i would like to be based on that one picture.

vadamalaik@upmc.edu
says:

My answers

1. Probe- Linear - high-frequency probe

2. Lung point- Lung sliding is ABSENT on the left side of the screen with Lung sliding PRESENT on the right side of the screen.

3. Immediate needle decompression should be done to relieve the pneumothorax on the side of the lung where the pictures are obtained

4.I would be confident to do needle decompression as the patient is hypotensive and hypoxemic. Given that the patient is on positive pressure ventilation, the pneumothorax should be decompressed emergently and cannot wait until x-ray chest is done.

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