Case Presentation:Darth

A 67 y/o male presents with shortness of breath for 1 day, acutely worsening over the past 3 ho

urs. The patient arrives via EMS with a ventimask in place. EMS tells you they gave your patient a breathing treatment en route as he was extensively wheezing. Your patient is unable to report any additional history due to his severe shortness of breath.

Review of Systems:

Unable to obtain due to severe patient distress.

PMHx/PSHx (via EMS):

DM, Hyerlipidemia, COPD, HTN, CHF

Medications/Allergies:

Unknown and unable to obtain

Physical Examination:

VS: Blood Pressure 198/110, Pulse 104, RR 28, Temperature 36.9F, Oxygen Saturation 87%.

The patient appears in significant respiratory distress, diaphoretic, tachypneic leaning forward in bed with a breathing treatment still being administered. On lung auscultation, you hear the following (click to play audio):

You order a stat portable CXR, however the technician won’t be available for another 10 minutes. You remember that your ultrasound machine is nearby and waiting to be put into action. You tell your attending to go grab his cup of coffee and decide to take matters into your own ultrasound capable hands. You first decide to perform a bedside lung ultrasound and observe the following:

https://youtu.be/k01Hht5fK98

You next decide to perform a bedside cardiac ultrasound and observe the following:

https://youtu.be/eOEvhO95DDA

https://youtu.be/eLifn8TH2cYA

Your CXR is finally performed and you quickly review the film. You feel fairly confident you now have the diagnosis and start with your new treatment plan.

CXR

Questions:

1.Why did this patient not respond to his initial albuterol treatment?

This patient was not having a COPD exacerbation. The patient had a ‘cardiac’ wheeze and required treatment for congestive heart failure.

2.Name 3 different treatment options for the patient in this vignette.

Non-invasive positive pressure ventilation (BIPAP or CPAP), Nitroglycerin, Loop diuretic (Lasix), After-load reduction (ACE-Inhibitor, Nicardipine).

3.Which transducer was used for the bedside lung ultrasound? Is this the appropriate probe?

A Phased Array transducer was used to complete the ultrasound. When evaluating for either A-lines or B-lines, you should use either the phased array or curvilinear probe to achieve the greater depths required to evaluate for the presence or absence of these artifacts. A linear probe should be used when assessing for a lung sliding/pneumothorax.

4.What is the difference between an A-line and a B-line?

A-lines are horizontal reverberation artifacts often seen in patients with a normal lung surface, though they may also be seen in patients with COPD. B-Lines are comet-tail artifacts suggestive of interstitial edema. Focal B-lines may be seen in the setting of pneumonia. Diffuse B-lines in both semi-thoraces are often associated with pulmonary edema seen in many congestive heart failure patients.

5.Name two different techniques to determine the ejection fraction on bedside cardiac ultrasound.

One of the most common techniques is known as E-point to septal separation (EPSS), and is utilized in the parasternal long axis while using M-mode echocardiography. Visual gestalt, Fractional shortening and Simpson’s Method of Disks can also be used.

6.Which is a better imaging modality (US or XR) for determining the diagnosis for the above patient? Bonus point if you provide a reference to support your claim!

Ultrasound!

Answers to be posted in 1 week! Please do not post answers in the comment sections until after 10/23/15.