Ultrasound Case 016

Presentation

A 50 year old male has an out of hospital cardiac arrest. ROSC is achieved rapidly on scene and he is brought in by ambulance hypotensive, agitated and confused.

You perform an abbreviated echo in ED to direct further investigations and management.

Subcostal view
View 2 – Parasternal long axis
Parasternal long axis


View 3 – Abdominal aorta transverse
Abdominal aorta transverse

View 4 – Abdominal aorta longitudinal
Abdominal aorta longitudinal


Describe and interpret these scans

IMAGE INTERPRETATION

Image 1: Poor quality subcostal cardiac view. Despite the poor view you can see a small pericardial effusion, you see the right heart is not dilated and is functioning well. The left heart looks to be contracting well but it is very difficult to be certain. You move to a parasternal long axis view.

Image 2: The parasternal long axis view. The most obvious feature is the markedly dilated proximal aorta which measures just over 6cm. It compresses the left atrium.

Image 3: Transverse view of the proximal abdominal aorta. This view shows a dissection flap in the non-aneurysmal abdominal aorta.

Image 4: An off axis attempt at a longitudinal view of the abdominal aorta. This confirms the dissection flap.


CLINICAL CORRELATION

Aortic dissection.

Echocardiography in the periarrest and postarrest situation is abbreviated, targeted and correlated with clinical suspicion. Even a few seconds of a suboptimal image can exclude several key diagnoses.

Is there evidence of:

  • a large pericardial effusion (tamponade)
  • right heart strain / DVT (Pulmonary embolism)
  • left ventricular dysfunction (cardiac failure)
  • a hyperdynamic empty left ventricle and empty inferior vena cava (hypovolaemia)

Ultrasound can then be use to search for the cause of hypovolaemia if it is not clinically apparent (e.g. intra-abdominal haemorrhage).

More advanced questions include. Is there:

  • severe valve dysfunction (e.g. a ruptured papillary muscle) ?
  • aortic pathology (dissection or aneurysm)?
  • regional wall motion abnormality (did ischaemia lead to arrhythmia)?
  • HCM (hypertrophic cardiomyopathy may have led to arrhythmia)?
  • …any other rarer cardiac pathology?

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An Emergency physician based in Perth, Western Australia. Professionally my passion lies in integrating advanced diagnostic and procedural ultrasound into clinical assessment and management of the undifferentiated patient. Sharing hard fought knowledge with innovative educational techniques to ensure knowledge translation and dissemination is my goal. Family, wild coastlines, native forests, and tinkering in the shed fills the rest of my contented time. | SonoCPDUltrasound library | Top 100 | @thesonocave |

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