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					                                                                                                   25/06/2011




                                                              Who should perform emergency
                                                                   echocardiography?
                                                             1.   Cardiac physiologists
       Emergency echo cases                                  2.   Cardiologists
                                                             3.   Emergency medicine specialists
                                                             4.   Intensivists
                                                             5.   Radiologists




                         Case                                                  Examination
 74 yrs, male                                               • Distressed and agitated, GCS 14
 Post-op left hemicolectomy (complete resection of Duke A   • SaO2 97% (28% O2, 4 l/min)
  colonic carcinoma)                                         • BP 74/30 (arterial line)
 PMH- hypothyroidism (on thyroxine) and angina (well
                                                             • HR 107/min, sinus
  controlled)
                                                             • Chest clear
 No anaesthetic complications
                                                             • HS normal
 Just arrived in HDU for post-op care
                                                             • Abdomen – laparotomy scar
 Sudden onset chest pain, dyspnoea then circulatory
  collapse




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                                                                25/06/2011




Focused echo, A4ch                      PLAX




      A2Ch                          Management

                     1. Aggressive IV fluids

                     2. IV diuretics

                     3. Inotropes

                     4. Back to theatre for exploratory laparotomy

                     5. Unsure




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                                                                                               25/06/2011




                Management                                           Case
                                                  • Male, 68 yrs
• Central line examined
                                                  • Acute dypnoea, cough & haemoptysis
• 3 way connector incompletely attached
                                                  • Background of low grade back pain (3/12)
• Diagnosis- air embolism
                                                  • PMH – Nil else
• Management- line sealed, fluid resuscitation,
                                                  • Rx – ibuprofen
  high flow O2




                Examination                               Focused echo, PLAX
• Cachectic
• SaO2 91% (15 litres)
• BP 108/60
• P104/min (sinus)
• HS normal
• Chest clear




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                                          25/06/2011




PSAX                       A4ch




                    Management

       1. Thrombolysis

       2. Catheter thrombectomy

       3. Heparin and longterm warfarin

       4. Emergency thoracotomy

       5. Other




                                                  4
                                                                                                                      25/06/2011




                      Progress
• CT abdomen and thorax
• Renal mass infiltrating via IVC into right atrium
• Associated central pulmonary embolism
• Anticoagulated
• Nephrectomy and radical resection
• IVC filter
• Chemotherapy




                          Case                                                    Progress
 24 yrs male, joyrider                                      • Aggressive fluid resuscitation, transfusion
 Lost control of car at around 80 mph, dual carriageway
                                                             • Skeletal survey- no sternal fracture
 Head on collision with HGV
                                                             • Fractures stabilised
 Extracted by fire service
                                                             • CT bilateral occipital lobe contusion, small frontal
 Not wearing seat belt, air bag deployed
                                                               haematoma, no cervical spine fracture
 Serious head injuries, bilateral humeral shaft fractures
 Likely blunt chest trauma                                  • Transferred to ITU for ventilation and post-op care




                                                                                                                              5
                                                                                                         25/06/2011




                  Progress                                                  A4ch

• Frequent ventricular ectopics

• Normal urea & electrolytes

• BP initially 110/64, drifting despite IV fluid and
  now noradrenaline




                     PLAX                                               Diagnosis
                                                       1. Trivial pericardial fluid – likely contusion

                                                       2. Clinically significant pericardial effusion

                                                       3. Pulmonary embolism secondary to trauma

                                                       4. Unsure




                                                                                                                 6
                                                                                                          25/06/2011




                     Progress                                               23 yrs, female

• CT thorax confirmed partial pulmonary transection           • Standby call to resus
  with leak of contrast into pericardium
                                                              • Collapse in shopping centre
• Continual transfusion requirement
                                                              • No history available
• Unstable transfer for cardiac surgery
• Successful repair of pulmonary root                         • Bystander CPR

• Eventual transfer to definitive rehab facility              • Cardiac output present when paramedics arrived




                    On arrival                                              Investigations
• Agitated and distressed                                     • pO2 9.6 (35% O2), pCO2 3.1, H+ 34
• GCS 13/15
                                                              • ECG – sinus tachycardia, right bundle branch
• BP 98/50, p 120/min
                                                                block
• JVP raised
• HS I + II + ejection systolic murmur at left sternal edge   • CXR – “no pneumothorax”

• Chest clear                                                 • CT brain - normal




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                                            25/06/2011




                 Question
The emergency medicine team want to
thrombolyse this patient with a presumed
pulmonary embolism. Does the echo support this?

1. Yes

2. No

3. Unsure




                                                    8
                             25/06/2011




A diagnostic procedure was
       performed…




                                     9
                                                                                 25/06/2011




                     Progress
• CTPA was negative (bedside D-dimer negative)
• Further history- father has epilepsy
• Witnessed tonic seizure in medical ward        N Engl J Med 2010; 363:266-74

• MRI brain – focal gliosis
Final diagnoses:
1. Epilepsy (now well controlled)
2. Secundum atrial septal defect (for closure)




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25/06/2011




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