(P83) RUSH to the Answer: A Case of Cardiac Injury Diagnosed on Bedside Ultrasound

Chief Complaint : A 63-year-old female presented as a rapid response from the outpatient CVIR suite after becoming hypotensive and unresponsive during an IVC filter removal procedure.

History of Present Illness : A 63 year old female with a past medical history of asthma, hypertension, diabetes, ovarian cancer and pulmonary embolism presented as a rapid response from the outpatient interventional radiology (IR) suite after she became hypotensive and unresponsive during an IVC filter removal procedure. The patient had reportedly received flumazenil and naloxone to reverse the effects of benzodiazepines and opioids that she had been given in case they were the cause of her hypotension. She also received glucose and a 500cc bolus of fluid with a reported improvement in her blood pressure and mental status. However shortly after arrival to the ED the patient had a systolic blood pressure of 30mmHg and aggressive fluid resuscitation was initiated.

Pertinent Physical Exam: Initial Vitals: BP 30/palp, HR 82, RR 15

General: Somnolent, not answering most questions
Head: Normocephalic, atraumatic
Neck: Supple
HEENT: Pale mucous membranes
Respiratory: Normal work of breathing
CV: Hypotensive, only carotid and femoral pulses palpable
Abd: Soft, nontender
Skin: Cool, pale

Pertinent Laboratory Data: Due to the patient's critical illness no pertinent laboratory data was able to be obtained in the emergency department.

Case Discussion: Due to the patient’s profound hypotension and altered mental status on arrival, a RUSH exam was performed at the bedside which identified a large pericardial effusion with signs of developing cardiac tamponade. This was highly suspicious for proximal IVC or right atrial injury and the cardiothoracic surgery team was immediately called. The patient was taken emergently to the OR where a large amount of pericardial blood and hematoma were evacuated. The right atrial appendage showed an area of bruising that was suspicious for a perforation. The patient was transferred to the ICU where she continued to recover well and was discharged on post operative day 7.
The above case describes a very unstable patient who’s diagnosis was obtained rapidly with bedside ultrasound using the RUSH exam. On arrival from the outpatient IR suite, the patient’s cause of hypotension was not known. It was only after the cardiac view of the RUSH exam that a pericardial effusion and developing tamponade was identified and appropriate management was able to occur. In this situation there were very few other options to evaluate the patient. She was too unstable to remove from the emergency department for a CT and labwork would have taken too long. Bedside ultrasound however was able to immediately identify a pericardial effusion and developing tamponade as the cause of this patient’s hypotension. The purpose of the RUSH exam, similar to the eFAST, is to identify pathology that needs to be intervened on immediately. Incorporation of bedside ultrasound into the evaluation of critically ill patients shortens the time to correct diagnosis and improves the accuracy of diagnosis. Our case is an example of bedside ultrasound being used to very quickly answer a clinical question that lead to a lifesaving diagnosis and supports the use of bedside ultrasound for all hypotensive patients.

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