Ultrasound Case of the Month

Case of the month from November 2016 

Part 1: Dyspnea 

A 49 year old male presents with gradually worsening SOB and orthopnea. He has no significant past medical history. A bedside ultrasound was performed:

This is a parasternal short view on bedside echo, which shows a pericardial effusion. Echo features of tamponade include RV collapse in diastole, as well as an IVC without evidence of respiratory variation (although there was some respiratory variation with this patient).

In addition, one can evaluate for pulsus paradoxus on cardiac echo. By placing the pulse wave Doppler at the tips of the mitral valve in an apical four-chamber view, you can evaluate the change in velocity across the valves through inspiration and expiration. A change of more than 25% in velocity with respiratory variation is consistent with tamponade physiology.   

Image 1: Evaluating for pulsus paradoxus on bedside cardiac echo. 

In terms of sizing an effusion:

Small effusion: <0.5cm (roughly corresponds to <100cc)

Moderate effusion: 0.5cm-2cm (roughly corresponds to 100-500cc)

Large effusion: >2.0 cm (roughly corresponds to >500cc)

For more information: 

Life in the Fast Lane

5 Minute Sono

Part 2: Chest Pain 

66 year old male presents to the ED with chest pain. Patient reports an episode of left sided throbbing pain with diaphoresis and dizziness. His symptoms have since resolved. An EKG was performed:

Image 2: EKG 

A bedside ultrasound was performed:

Wall motion abnormality in the LAD territory

This patient’s ECG is consistent with Wellen’s syndrome, and their troponin was 13.1.  The cardiac catheterization report showed a 95% occlusion of the mid LAD. He received two drug eluting stents. 

For more information:

Ultrasound Podcast

Resident Reviewer: Dr. Chana Rich

Faculty Reviewer: Dr. Kristin Dwyer