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Clinical Case 068: Surviving sepsis. Serial scans for super-sick sheila

My newly arrived UK RMO Dr Laura Castle and I managed a sick lady today and we used the bedside ultrasound to assist us in 5 modalities.  Now even I struggle to use US that much, but this case required a lot of thinking and it happened on a slow Sunday – so not much back up from the lab or Xray department.

60 yo woman presented with shortness of breath, tachypnoea, hypotension and severe RUQ / chest wall pain.  She had a background history of CLL, had recently flown across the globe and had known gallstones with frequent biliary colic whilst on holidays.

She basically had septic shock – MAP of 65, HR 130, vasodilated and had a good going oxygen requirement (15l/min => 94% Spo2).  She was tachypnoeic RR= 25 with marked pleuritic pain in the RUQ / lower chest (bad enough to need IV morphine).

So here is how we used the bedside US over the initial few hours of management:

On arrival her IVC was collapsing to nothing with tidal breathing – so we gave a few litres and rescanned.

After this resus the IVC was ~ 2cm, with about 50% collapse as shown.  We pressed on with another litre at this point. It was ~ 5L in when we were satisfied we had adequate IVC scans to suggest we were on the happy part of the Starling curve.

The presence of hypoxia / hypotension, chest pain and a history of recent long-haul flight got us a little worried about a big PE. Before we got the chest imaged we decided to look at the heart for evidence of RV strain, that might suggest a PE – there was none. The RV was small and the septum bowed into the right side – so no evidence of high right pressures. This combined with the flat IVC made a big PE less likely.

I am still finding my feet when it comes to US for pneumonia. And on this case I missed it – and I know why. I did a scan of the front and back segments – but omitted the axilla! At the time I saw some basal changes that looked like a trace of ARDS or irregular pleural surface. After the CXR I saw my error – the consolidation was just touching the posterior pleura – so hard to see on the US – but readily apparent when I scanned the axilla. See this image of hepatized lung.

Sorry not the best pic – however there is a clear view of lung structure beneath the pleura – this is equal to consolidation on a CXR.


Thinking outside the box, I wanted o make sure we were not missing a cholangitis or cholecystitis as a cause of RUQ pain and sepsis. We still had a few hours o wait for a CXR – so I wanted to get the ABs started and not miss anything. So we scanned the GB – normal wall thickness, normal CBD, no fluid around he bag, a few stones – but they were fundal. So I thought on balance the Hx of biliary colic was a red herring – not a likely cause of the RUQ pain a t this point.

Arterial access in a patient with a crashing blood pressure, tiny arteries etc can be tough. There is a bit of evidence (Blaivas et al)to suggest that we are better served by US-guided lines than the old school blind approach. Personally I find that the ones with bounding pulses are not too bad, so I reserve US guidance for the tough ones – like our lady

After a few hours of resuscitation we were winning. CO was OK with a smidgen of phenylepherine. The CXR was telling.

Despite what we think – we are not so great at detecting big time lung lesions on clinical examination.  And I learned why it is important to look at the axilla – to get a view of the lateral pleural margins when scanning for pneumonia.

Well, that is how I like to use bedside US in my shop.  For me it eliminates a lot of the guesswork and reliance on labs and XRays – however it is a constant challenge.

A steep learning curve, US is so user-dependent that we each must have insight into how reliable the pictures we get are and interpret them in the light of he clinical picture.  In order to make it useful there is a necessary, ugly period we all must go through in order to relearn a set of skills that I think will be invaluable in the future.

Any thoughts or questions?

Casey

Comments

  1. Hey casey,
    trying my best to get some “probe time”
    i guess im mid ugly part for a few things but happy with others.
    Not used for radial arterial lines but always use for femoral ones.
    How do the learning curves compare between skills/exams
    I find identifying pneumothoracies not too difficult but finding
    the ECHOs and lung imaging bit more difficult.
    any hints on skilling up?
    cheers
    andre

  2. Adrian Goudie says

    Hello Casey,
    once again an interesting case that highlights the breadth and utility of ultrasound (from one ultrasound-phile to another). As you say, once you’ve climbed the hill of the initial learning period (and there’s no doubt it can be frustrating while you do), you suddenly find that it’s helpful in ever increasing ways. The reassurance of ruling out something unlikely, like the GB in this case (so unlikely that you can’t justify formal imaging for it) is, I think, as valuable as making the unexpected diagnosis, even if not so exciting. I was recently asked to scan a septic bloke who’d recently had renal stones (to check for ?obstructed infected kidney) and whilst muttering rude words because I was struggling to get good cardiac views (to assess his contractility and filling) realised that the lung was ‘hepatised’ from pneumonia. Whilst it still might not be common, it’s pretty amazing that now this is an accepted event, whereas even 10 years ago you’d be stared at as mad for suggesting this was how you could make that diagnosis.
    As a shameless plug (as I’m on the organising committee), anyone who wants to see and listed to one of the world’s lung ultrasound experts, Prof Gebhard Mathis will be in Sydney at the end of the month giving a day of lectures and a workshop on lung ultrasound at the ASUM annual meeting.
    cheers
    Adrian

  3. …wish could make that. Excited that they’ll be an USS workshop at the Rural Medicine Australia conference #RMA2012 – and good to hear there’s an iBook coming out on USS soon, which may help accelerate the learning curve

    • Hey Tim. iBook for Bedside Ultrasound – does it get any better than that!
      Little birdie told me there is a chapter written for rural docs, by Aussie doc on your favourite topic – Trauma: US in adverse situations.
      Can’t wait for that one to pop up in iTunes…. had a sneak peek – it looks pretty slick.
      Casey

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