Hennepin Ultrasound Images of the Week
On Valentine’s Day, we share an interesting case seen in the Emergency Department.
The patient arrived via EMS from a group home with reports of shortness of breath and vomiting. Initial Sp02 was 50% improving to 70% with CPAP en route. The patient was noted to be hypertensive and tachycardic in the ambulance so nitroglycerin x3 was given. Immediately upon arrival to the stabilization room, a bedside ultrasound was performed and the physician noted scattered B lines. The patient was intubated and the following chest x-ray was obtained.
The patient was given IV Lasix and started on a nitroglycerin drip for presumed pulmonary edema and heart failure. Additional ultrasound images were then obtained.
Notice the “kissing papillary” muscles on this parasternal short axis. Below, red arrows point to papillary muscles in short axis.
Rapid ultrasound assessment of shock states is most useful at extremes of pathology. In this case, the findings of a fully collapsing left ventricle indicate a hyperdynamic heart approaching an ejection fraction of 100% Parasternal long and apical 4 chamber views confirmed low ventricular filling volumes. In addition, IVC images showed a flat IVC with respiratory variation, even while intubated.
The patient’s nitroglycerin drip was stopped. IV fluids were started and broad spectrum antibiotics were given out of a concern for sepsis secondary to aspiration pneumonia.
Learning points:
- When a patient is critically ill, rapid assessment of cardiac function and volume status are critically important. Extremes of volume status inform appropriate therapy. In this case, patient’s hyperdynamic left ventricle and flat IVC are clearly indicative of intravascular volume depletion. Look for Kissing Papillaries!
- B lines may indicate a number of different pathologies and should be interpreted in context of cardiac function and clinical presentation. B lines may indicate pulmonary edema but can represent various pathologies affecting the interstitial lung space including pneumonia. Patient was ultimately diagnosed with multifocal pneumonia likely secondary to aspiration.
Patrick McCarthy, MD is an emergency medicine ultrasound fellow at Hennepin County Medical Center.
