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POCUS Case Conference Archive

Cardiogenic Shock

Presentation Date

10-18-17

Presenter

Dr. Christopher Parkhurst
PGY4,Critical Care fellow

Expert Consultant(s)

  • Dr. Matthew Vorsanger (Cardiology)
  • Dr. Lindsay Lief (Crit. Care)
  • Dr. David Weir (Crit. Care)
  • Dr. Sophia Lin (ER)

 

History

A 20 year old man w/o  significant PMHx transferred from the LMH ICU to UES ICU for further evaluation and management.

  • Several days of abdominal pain before presentation to LMH
  • Transaminitis, acalculous cholecystitis by abdominal imaging
  • Intra-abomdinal pathology was being considered
  • Overnight with hypotension and hypoxia -> transferred to LMH MICU

PMHx: None

Meds: None

Physical Exam:

  • Young man, on a non-rebreather, diaphoretic
  • AAO x 1  but speaking to us, appeared terrified 
  • SBP 110s, HR 120s
  • Heart: Regular with normal heart sounds
  • Lungs: Crackles bilaterally
  • Abdomen:  diffusely tender
  • Extremities: cool to touch

Labs:

Point of Care Ultrasound

Parasternal Long-axis view

Low PLAx (note that the septum is less horizontal than in the standard PLAx). This will tend to over-estimate RVOT size,

Severely globally decreased LV contractility. LV is not particularly dilated, and LA is not large. Also, no pericardial effusion is seen.

This image alone in this clinical context is sufficient to make a Dx of acute LV failure with cardiogenic shock.

“Normal” BP in young patients does NOTr/o shock and is NOT reassuring. 

 

PSAx

  • very poor LV contractility
  • paradoxical septal motion
  • RV is normal size
  • No pericardial effusion

Apical 4-Chamber View

(LV-focused)

Severely decreased systolic LV fx. 

LA is not enlarged. Note, however, that later in the clip the probe tilts posteriorly into coronary sinus view.

This may significantly under-estimate LA size.

See how to perform A4 properly.

Ideally am RV-focused view would be obtained as well in order to assess RV size and fx. Remember, that there were some concerns regarding RV size on PLAx.

Subxiphoid long-axis view

No pericardial effusion.

Very poor LV systolic fx is confirmed.

RV may be enlarged, but can not be confidently evaluated. Be cautious of ruling out LV enlargement based on this view alone.

Subxiphoid IVC long-axis view

Dilated IVC, w/o response to respirations  (a.k.a. plethoric). This is consistent with elevated RA pressure. 

Note tachypnea present during the study.

Interpretation of Findings

Carcinogenic shock, likely acute myocarditis. 

  • heart failure service and CT surgery consulted STAT
  • The patient was intubated (with precautions for shock)
  • Taken immediately to the cath lab: LHC unremarkable, RH Bx performed
  • LV Assist device (Impella) placed
  • Patient placed on V-A ECMO and taken to CT-ICU
  • Cardiac Bx: lymphocytic myocarditis
  • Remained on ECMO for 7 days with increasing LV pulsatility
  • Successfully weaned from ECMO.
  • Extubated and transferred to CCU.

Repeat Point of Care Ultrasound

PLAx

Before
After

PSAx

Before
After

A4

Before
After

Follow Up

  • Discharged home
  • Seen in cardiology clinic- doing well, back to normal baseline
  • Official TTE at that time without any abnormalities

Papers Presented

Volpicelli et al., Intensive Care Med (2013) 39:1290–1298

Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. (RUSH protocol)

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