Ultrasound Case 2: Discussion
Ultrasound Case 2: Discussion
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Case2: Left lower quadrant scan. Case2: Left subcostal coronal scan. Dilated, fluid filled stomach and fluid filled bowel loops. The ultrasound exam revealed a few B lines at the left lung base, and a diaphragm located quite high on the left, almost in the axilla above the nipple line. ‘A’ profiles were seen anteriorly and on the right. A large, fluid-filled structure was noted in the left upper quadrant over 20 cm by 20 cm, as well as several smaller fluid-filled structures, corresponding to loops of ileus. There was massive gastric dilation in the patient, secondary to ileus. The particulate matter seen in the fluid-filled structure is likely remnants of a last meal. The respiratory distress was due to the abdominal distension and resultant small lung volumes and atelectasis. The gastric dilation itself may have triggered the rapid atrial fibrillation, which in turn may have contributed to dyspnea. The patient was given a dose of digoxin and a naso-gastric tube was inserted, resulting in drainage of 2 liters of gastric content. His dyspnea subsided and he converted back to a normal sinus rhythm by morning. A follow-up ultrasound exam was performed after he diuresed 700 cc’s in the ensuing hours, and his BP dropped to 90/50. He was found to have an IVC of less than 5 mm that collapsed completely during inspiration, and his LVEF was now hyperdynamic. These symptoms were consistent with volume depletion, induced by third-spacing and a diuretic empirically given for possible congestive heart failure. Case 2 illustrates the ease and rapidity with which the correct diagnosis is made and how the follow-up is critical. Without bedside ultrasound, a diagnosis would likely have been delayed or lacked immediate certainty, and unchecked, the situation could have led to further complications. When confronted with an unusual or unfamiliar structure in an ultrasound image, clinicians can first think anatomically of the area, looking at the surrounding structures, and examining the structure in both axes. This will often result in accurate identification. If in doubt, do not hesitate to escalate to the next level of examination (a radiologist performing the ultrasound, or a CT scan), remembering that rapid bedside examination is not meant to exclude other diagnostic modalities in our armamentarium. At times, anatomy may be so distorted it becomes unreliable.
Case courtesy of the Critical Care & Ultrasound Institute, excerpted from 50 Cases in Bedside Ultrasound, by Dr. P. Steinmetz and P. Rola, available in the Apple Store.