Chris Fox, MD Professor and Interim Chair Department of Emergency

Transcription

1 Close Calls with the Executioner: Where POCUS Avoided Misdiagnosis Chris Fox, MD Professor and Interim Chair Department of Emergency Medicine

2 En route with 22 year old female Asthma attack witnessed by next door neighbor Bradycardic, hypotensive and cyanotic in field PEA on arrival

3 En route with 22 year old female

4 En route with 22 year old female

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6 Altered Mental Status 32 yo Vietnamese female brought in by paramedics. Family called 911 because she was sleepy and confused. En route she was hypotensive and difficult to engage but she spoke Vietnamese only. Arrival vital signs: Sinus tach at 140s, BP 70/palp, RR 16, temp 36.9, pulse ox = 94% Unresponsive to painful stimuli; GCS 3 Intubated and efast scan done simultaneously

7 Altered Mental Status

8 Altered Mental Status

9 Altered Mental Status

10 Triage Shift ugh 38 yo female with RLQ abdominal pain and weakness for one day. PMH: Diabetes PSH: none Meds: metformin PE: BP 90/55, HR 130, RR 16, T 37.3, Pulse OX 98% UCG ordered in triage is positive, patient unaware she is pregnant

11 Triage +UCG and Abd Pain = FAST

12 Ectopic Transabdominal View (out in triage)

13 Take Home Points Leverage FAST scan to raise concern for your patient While endovaginal approach is often required, consider transabdominal initially for a quick diagnosis Just because a fetus is large and has fetal movement, do not assume its within the uterus!

14 52 yo Male h/o HTN, CAD, and afib on Coumadin with Fever and Hypotension PMH of CHF and poor LV function, with fever and cough PE: HR 122, BP 80/50, RR 22, Temp 39.9, Pulse Ox 78% Difficult to stick anticoagulated patient I m a vasculopath Nurse performs ultrasound guided IV in triage to get important labs/cultures

15 52 yo Male h/o HTN, CAD, and afib on Coumadin with Fever and Hypotension While the labs are percolating, an AP CXR is read as bilateral patchy infiltrates vs. CHF by attending radiologist Ultrasound of heart and lungs is performed in triage by a medical student out in triage

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17 Ultrasound of Left Chest

18 Ultrasound of Right Chest

19 52 yo Male h/o HTN, CAD, and afib with Fever and Hypotension Labs show: WBC 18K, Lactate 5.8 Patient now being seen by EM resident and attending who perform VTI and IVC collapsibility (after 1.5L of fluids) and determine: VTI in the teens with 25% swings with respiration and IVC collapsing > 70%

20 52 yo Male h/o HTN, CAD, and afib with Fever and Hypotension MAP is still less than 75, central line is carefully placed under ultrasound guidance with ultrasound confirmation in order to infuse norepinephrine

21 52 yo Male h/o HTN, CAD, and afib with Fever and Hypotension MAP is still less than 75, central line is carefully placed under ultrasound guidance with ultrasound confirmation in order to infuse norepinephrine

22 52 yo Male h/o HTN, CAD, and afib with Fever and Hypotension MAP is still less than 75, central line is carefully placed under ultrasound guidance with ultrasound confirmation in order to infuse norepinephrine

23 52 yo Male h/o HTN, CAD, and afib on Coumadin with Fever and Hypotension 5 hours later, patient in the ICU, by now 3 liters of IVF was infused. Intensivist repeats VTI: 30 with only 9% respiratory variation and fluids reduced to maintenance Due to persistent elevated lactate, and poor LV function, norepinephrine was discontinued and dobutamine was initiated to help improve the contractility. After 48 hours the lactate returned to normal, BiPAP was discontinued, and the patient was transferred out of the ICU.

24 31 year old Female with Cough and Syncope Persistent fever for 6 days despite taking tylenol/motrin NyQuil and DayQuil around the clock not helping Went to PMD and got azithromycin, started yesterday No other past medical history, no medications PE: HR 110, BP 86/50, RR 20, Temp 38.3, Pulse Ox 96% Lungs: scattered ronchi Legs: bilateral 2+ pitting edema Influenza B Positive

25 31 year old female with cough and syncope What should we do next? Chest Xray consistent with viral pattern

26 31 year old female with cough and syncope What should we do next? CT Angio?? Fresh set of vitals: HR 120, BP 98/65, RR 18, Temp 38.0, Pulse ox 96% ECHO?

27 31 year old female with cough and syncope ECHO?

28 31 year old female with cough and syncope ECHO? EPSS = 20

29 What is E Point Septal Separation? Distance from TIP of anterior mitral valve to the septal wall Using M-mode EPSS is measured during diastole Less than 7 mm suggests normal LV function EF = x EPSS (mm)

30 31 year old female with cough and syncope ECHO? EPSS = 20mm so EF = 25.5%

31 31 year old female with cough and syncope ECHO?

32 31 year old female with cough and syncope Admitted for Viral Myocarditis Tamiflu given Diuresis Discharged after 7 days with 55% ejection fraction

33 57 yo Female with Shortness of Breath for 1 Month University Professor, international expert Mild shortness of breath for one month, worsening for 2 days No chest pain; mild leg swelling comes and goes No medications, no recent injuries, non-smoker PE: HR 95; BP 110/65; RR 22; Pulse Ox 94%; Temp 37.3 Lungs clear Heart: no murmurs Legs: trace pitting edema on right leg D-Dimer 365

34 57 yo Female with Shortness of Breath for 1 Month Next steps? CXR: unremarkable.

35 57 yo Female with Shortness of Breath for 1 Month

36 57 yo Female with Shortness of Breath for 1 Month

37 57 yo Female with Shortness of Breath for 1 Month

38 Pulmonary Embolism = When RV > LV RV LV

39 TAPSE: Tricuspid Annular Plane of Systolic Excursion

40 TAPSE: Tricuspid Annular Plane of Systolic Excursion

41 Normal TAPSE?

42 7.8 mm = RV Dysfunction

43 Mechanisms of RV Dysfunction in Critical Patients Lahm; J Am Coll Cardiol 2010;56: )

44 TAPSE PAPSE data

45 38 yo Female Bus Driver BIB Paramedics Rapid onset of shortness of breath while driving her bus today Smokes 5 cigarettes per day; takes oral contraceptives Poor historian, BMI of 75 PE: HR 135; BP 70/40; RR 22; Pulse Ox 96%; Temp 37.1 Lungs clear Heart: Distant heart sounds

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47 Patient Hand-off 16-year-old female presented with 3 months of dyspnea on exertion and one episode of near syncope

48 IVC

49 IVC

50 Two months later Identical Twin has Similar Symptoms! Also diagnosed with bilateral pulmonary emboli

51 70 year old male with choking episode at local restaurant Bystander performed the Heimlich maneuver prior to paramedic arrival

52 70 year old male with choking episode at local restaurant My belly hurts where that guy squeezed me

53 70 year old male with choking episode at local restaurant

54 AAA

55 AAA

56 Syncope on Catalina

57 Dissection

58 Aorta Ultrasound Can be easily learned and will save lives if regularly performed Maintain a high index of suspicion and low threshold Use anatomic landmarks, doppler, and repositioning maneuvers to help you Implement in undifferentiated hypotension protocol

59 Summary Ruptured Ectopics Pneumonia Fluid Resuscitation Central Line Placement Viral Myocarditis with Low EF Pulmonary Embolism Tamponade DVT AAA