Damn I love the U/S

[spyderdoc]

A 68 yo lady came to the ED by ambulance. The nurse tells me she has a BP of 78/40 (Rt arm). I go in and the medics tell me she was doing kitchen work, developed severe CP that radiated to the Lt arm, clutched her chest and syncoped. She was alert now, but confused. I felt a prominent abdominal aortic pulse, and diminished pulses on the Rt DP/PT compared to the left side. I grabbed the handy U/S machine, and looked to see if she had a AAA. It turns out that her AA was normal diameter, but I saw the AA was septated! I had the nurse check the BP on the Lt arm and it was 115/50. So I ordered the stat CT, and she had a type A dissection from the root to the iliacs! Went right to the OR...I will check tomorrow on her outcome...
Damn I love the ultrasound! Able to see the intimal flap of a dissection. Very much expedited this lady's trip to the OR...

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[DrQuinn]

Originally posted by spyderdoc
A 68 yo lady came to the ED by ambulance. The nurse tells me she has a BP of 78/40 (Rt arm). I go in and the medics tell me she was doing kitchen work, developed severe CP that radiated to the Lt arm, clutched her chest and syncoped. She was alert now, but confused. I felt a prominent abdominal aortic pulse, and diminished pulses on the Rt DP/PT compared to the left side. I grabbed the handy U/S machine, and looked to see if she had a AAA. It turns out that her AA was normal diameter, but I saw the AA was septated! I had the nurse check the BP on the Lt arm and it was 115/50. So I ordered the stat CT, and she had a type A dissection from the root to the iliacs! Went right to the OR...I will check tomorrow on her outcome...
Damn I love the ultrasound! Able to see the intimal flap of a dissection. Very much expedited this lady's trip to the OR...

Wow! Good for you!
I'm guessing she was a nice thin lady (prominent aorta)...

Do you think you would have done that on a 300#er?

Anyways, awesome!

Q, DO

 

[roja]

This is why I am doing a fellowship in U/S. It is amazing.

Great case!

 

[droliver]

Nice pickup, but it would seem that you'd already made the diagnosis without the ultrasound on your physical exam & her stereotypical history for disection. Did the U/S change what you would have done? I don't think it added much except for some (well deserved) self congratulation & immeadiate gratification. There must have been a huge disection (and a skinny lady) for you to see that. I'm a little surprised they rushed her to the OR with a disection that had already propagated down to her illiacs. My experience with those has been that they're very reluctant to operate except on the most favorable proximal disections

 

[southerndoc]

Originally posted by droliver
Nice pickup, but it would seem that you'd already made the diagnosis without the ultrasound on your physical exam & her stereotypical history for disection. Did the U/S change what you would have done? I don't think it added much except for some (well deserved) self congratulation & immeadiate gratification. There must have been a huge disection (and a skinny lady) for you to see that. I'm a little surprised they rushed her to the OR with a disection that had already propagated down to her illiacs. My experience with those has been that they're very reluctant to operate except on the most favorable proximal disections

Why do I get the sense that you're anti-EM? Maybe I'm wrong, but your posts give me that impression.

 

[Docxter]

Originally posted by spyderdoc
A 68 yo lady came to the ED by ambulance. The nurse tells me she has a BP of 78/40 (Rt arm). I go in and the medics tell me she was doing kitchen work, developed severe CP that radiated to the Lt arm, clutched her chest and syncoped. She was alert now, but confused. I felt a prominent abdominal aortic pulse, and diminished pulses on the Rt DP/PT compared to the left side. I grabbed the handy U/S machine, and looked to see if she had a AAA. It turns out that her AA was normal diameter, but I saw the AA was septated! I had the nurse check the BP on the Lt arm and it was 115/50. So I ordered the stat CT, and she had a type A dissection from the root to the iliacs! Went right to the OR...I will check tomorrow on her outcome...
Damn I love the ultrasound! Able to see the intimal flap of a dissection. Very much expedited this lady's trip to the OR...

Great pickup on the US. However, be aware that you were extremely lucky that you saw the dissection. US has very poor sensitivity in detecting aortic dissection. Some would even argue that if a CT is immediately available, you should not waste the patient's precious time doing an ultrasound if you have a high suspicion of dissection. If CT is not immediately available, well, that's a different story. I have seen more than one patient code and die while people were futsing around in the ER trying to US the aorta.

The same goes for suspected AAA rupture. If the patient presents with Sx of AAA rupture, don't waste time with the US. Get the stat CT. One of our ER attendings was sued (had to eventually settle) in a case that he wanted an US to r/o AAA rupture instead of getting a stat CT. Most of the time the leak is retroperitoneal and you won't see much on US. Also, often you can't visualize the entire legth of the aorta and proximal common iliacs behind bowel gas. I have seen people miss a AAA since they saw the IVC which was of normal caliber. While US is great for detection and follow-up of AAA size, it's not that useful at all in acute cases of suspected rupture, especially if the patient is known to have AAA. Suppose you see a big aorta on US, so what?? You still couldn't exclude a leak. While US is a great tool, not using it appropriately can be very damaging to the management of patients.

 

[spyderdoc]

Originally posted by Docxter
Great pickup on the US. However, be aware that you were extremely lucky that you saw the dissection. US has very poor sensitivity in detecting aortic dissection. Some would even argue that if a CT is immediately available, you should not waste the patient's precious time doing an ultrasound if you have a high suspicion of dissection. If CT is not immediately available, well, that's a different story. I have seen more than one patient code and die while people were futsing around in the ER trying to US the aorta.

The same goes for suspected AAA rupture. If the patient presents with Sx of AAA rupture, don't waste time with the US. Get the stat CT. One of our ER attendings was sued (had to eventually settle) in a case that he wanted an US to r/o AAA rupture instead of getting a stat CT. Most of the time the leak is retroperitoneal and you won't see much on US. Also, often you can't visualize the entire legth of the aorta and proximal common iliacs behind bowel gas. I have seen people miss a AAA since they saw the IVC which was of normal caliber. While US is great for detection and follow-up of AAA size, it's not that useful at all in acute cases of suspected rupture, especially if the patient is known to have AAA. Suppose you see a big aorta on US, so what?? You still couldn't exclude a leak. While US is a great tool, not using it appropriately can be very damaging to the management of patients.

What you are saying goes against everything that EM U/S is for. Rapid, quick diagnosis. If an unstable pt comes in and you suspect a AAA, do the U/S, which takes all but 30 seconds to do, then call vascular surgeon based on your 30 second U/S. You can get your stat CT, which in any well oiled ED will take at least 15 min to do. Even so, are you going to send an unstable pt to the CT scanner to die there? In residency, haven't you learned that the road to death begins in the radiology suite??? Talk about a lawsuit...
In the last 2 years since finishing residency, I have sent 3 ruptured AAA's to the OR based on the rapid use of the Sonosite. One still died, the other 2 survived. If they were delayed 15 or so more minutes waiting for the CT to be done, who knows if the 2 survivors would have made it....

As far as the patient that I started the thread on. She did not have a classic story initially. CP and syncope can be a multitude of things...Arrhythmia, MI, ventrcle wall rupture, tamponade just to name a brief few... I was looking for both a pericardial effusion, and the aorta as well. Her dissection did go from the root to the iliacs and into the brachials...So I was lucky to see the intimal flap. That sealed the Dx for me. She is post op today, and doing ok....

 

[roja]

STAT CT in our institution still takes 20-30 minutes. It is also on another floor, so anyone not stable, its out of the picture.


And like many things, U/S is very user dependent. I think as more and more research comes out, it will prove for many things to be the standard of care.


And for type A dissections, you can look for the 'mercedes bens' sign in the parasternal long view. There was a study of 6 patients with type A dissections that all had this sign. Not very powerful but can help you make a decision.

 

[Docxter]

Originally posted by spyderdoc
What you are saying goes against everything that EM U/S is for. Rapid, quick diagnosis. If an unstable pt comes in and you suspect a AAA, do the U/S, which takes all but 30 seconds to do, then call vascular surgeon based on your 30 second U/S. You can get your stat CT, which in any well oiled ED will take at least 15 min to do. Even so, are you going to send an unstable pt to the CT scanner to die there? In residency, haven't you learned that the road to death begins in the radiology suite??? Talk about a lawsuit...
In the last 2 years since finishing residency, I have sent 3 ruptured AAA's to the OR based on the rapid use of the Sonosite. One still died, the other 2 survived. If they were delayed 15 or so more minutes waiting for the CT to be done, who knows if the 2 survivors would have made it....

Well, I guess there are institutional differences. At our place a STAT CT takes less than 5 min if no one is in being scanned already. The scanner is inside the ED patient area.

"If an unstable pt comes in and you suspect a AAA, do the U/S, which takes all but 30 seconds to do, then call vascular surgeon based on your 30 second U/S."

First, in the majority of patients you can't evaluate the entire abd. aorta and proximal iliacs in 30 sec unless they're extremely thin and have no bowel gas. If you have devised a new method that you can share with us, please let everyone know how.

In your approach, you'll be sending a whole lot of false positive cases to the OR. The problem is that a large percentage of all people above 70 coming through the door have some degree of AAA. If they have happen to have abd. pain +/- hypotension, would you send all of them to the OR for an emergent AAA repair just by doing an ultrasound and seeing a AAA on US? The vascular surgeons will not be happy!!! The problem is the ultrasound alone will not add much information to the management in the vast majority of cases.

I ask the question again, suppose you see a AAA on US, so what? How do you know it's leaking? In the vast majority of patients, it's only going to be an incidental finding anyway, unrelated to the patient's Sx. US is very very poor in Dx of a leak since they're almost always retroperitoneal initially. If you see a blood filled abdomen, then it's often too late and the patient will probably die unless someone clamps the proximal aorta right there in the ER (seen it done once by a vascular surgeon - patient became paraplegia likely due to lack of blood to the cord by choking off a spinal artery - happens during surgery too). If the patient is very unstable (frank shock), that is a different story and yes, you can't send the patient to the CT scanner. But most patients can go and get their CT and get a firm diagnosis. And a you HAVE to go with the patient to the scanner. If you can't afford doing that, well....

 

[Docxter]

Originally posted by roja
STAT CT in our institution still takes 20-30 minutes. It is also on another floor, so anyone not stable, its out of the picture.


And like many things, U/S is very user dependent. I think as more and more research comes out, it will prove for many things to be the standard of care.


And for type A dissections, you can look for the 'mercedes bens' sign in the parasternal long view. There was a study of 6 patients with type A dissections that all had this sign. Not very powerful but can help you make a decision.

True. Also, in a fair percentage of patients with involvement of the aortic root in type A, you can see a flap on echo in the left ventricular outflow tract view. You can even use a sonosite in the ER to see it.

 

[Coleman]

In general, I am a big fan of management discussion, always lively! I do appreciate the exercise because only when questioned does one truly gain an understanding of the topic. Coleman, 2002.

On that note, in regards to Docxter's comments:

The facts of patients with AAA:
autopsy of patients 50 and older: 2-4% w/AAA*
men aged 65 and older: 5-10% w/AAA*
*Rosens 5th ed. page 1177, Table 81-1

so we can conclude that not all people over 70 have some degree of AAA, in fact, very few do.

Docxter said:

all people above 70 coming through the door have some degree of AAA. If they have happen to have abd. pain +/- hypotension, would you send all of them to the OR for an emergent AAA repair just by doing an ultrasound and seeing a AAA on US? The vascular surgeons will not be happy!!!

So, a 72 year-old female presents to the ED w/abdominal pain, bp of 70/40 and U/S reveals a AAA and you are not going to contact vascular?

Rosen: page 1183
In symptomatic patients (abdominal or flank pain w/hypotension):
If an AAA can be diagnosed with bedside testing (US) the surgeon will often proceed immediately to the OR with a clinical diagnosis of aneurysm rupture, because a delay in surgery places the patient with a ruptured AAA at risk for sudden and unpredictable hemodynamic deterioration

Surgical mortality in patients with ruptured AAAs is approximately 50% and has shown little improvement in the past two decades. Hypotension is the most important factor predicting a poor outcome; a low initial hematocrit also increases the likelihood of perioperative death.

When patients who do not reach the OR are considered, the overall mortality rate is 80% to 90%

Docxter, given all this information, I would argue that the standard of care in symptomatic hypotensive patients with a AAA on bedside U/S, whether new or old, warrants IMMMEDIATE consultation and likely surgery, and the need for CT is questionable depending on your vascular surgeon.

For those interested in more reading, check out:
Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years.
Acad Emerg Med. 2003 Aug;10(8):867-71.

 

[Docxter]

Originally posted by Coleman

so we can conclude that not all people over 70 have some degree of AAA, in fact, very few do.
Docxter said:
all people above 70 coming through the door have some degree of AAA.

Nice job of twisting my words and then answering it. I never said "all people above 70 coming throughthe door". I said " a large percentage of all people above 70". And yes, I do consider a prevalence of >10% to be a large percentage. [/B]

So, a 72 year-old female presents to the ED w/abdominal pain, bp of 70/40 and U/S reveals a AAA and you are not going to contact vascular?

Contacting vascular is a good thing. Sending them all to the OR is not. In my hospital, the vascular surgeons trust the judgement of EM docs and meet the patients only in the OR just based on the EM docs' assessment. Apparently this is not the case and certainly should not be the case at many other places.

Suppose a 75 y/o comes to the ER with sepsis, has a BP of 85/60 and is afebrile (not uncommon in the elderly). He happens to have a AAA as well, confirmed on US. In your book, this patient would be sent for immediate AAA repair, right?

Docxter, given all this information, I would argue that the standard of care in symptomatic hypotensive patients with a AAA on bedside U/S, whether new or old, warrants IMMMEDIATE consultation and likely surgery, and the need for CT is questionable depending on your vascular surgeon.

Sabiston's Textbook of Surgery:
"If the patient is unstable and an abdominal aortic aneurysm has been previously diagnosed or a pulsatile abdominal mass is present, no further evaluation is performed and the patient is transferred to the operating room without additional tests. Stable patients with a questionable diagnosis should undergo CT scanning, which can confirm the presence of an aneurysm as well as demonstrate its extent, the site of rupture, and the degree of iliac involvement. In patients not stable enough to undergo CT scanning, the presence of an aneurysm can be confirmed by bedside ultrasound. This does not demonstrate aortic rupture but does confirm the presence of an aortic aneurysm. "


For those interested in more reading, check out:
Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Acad Emerg Med. 2003 Aug;10(8):867-71.

In this study they took only 10 of 29 symtomatic AAA patients to the OR. The paper doesn't say much other than ER US can accurately diagnose AAA. Duh? Didn't we know that before this paper?

 

[Docxter]

Some related issues. What is the most common cause of the physical finding of pulsatile abdominal mass in the abdomen?

A normal aorta with normal pulsations.

What's the accuracy of physical exam in AAA?

Most patients with aneurysms are not thin and most aneurysms are less than 6 cm. Under these circumstances, physical examination may be unreliable, resulting in 50% false-positive and 50% false-negative results. Sabiston's textbook of surgery.

To paraphrase Sabiston's, physical exam is "almost" useless in the diagnosis of AAA. I also get a kick out of some docs feeling an "aneurysm" in non-aneurysmal dissection patients.

How to improve one's AAA exam skills?

An important feature on physical examination is detection of expansile pulsation, where the gap between both hands placed on either side of the aneurysm widens with each systole. This finding may help to separate the aneurysm from normal aortic pulsations.

 

[Coleman]

Docxter,

I did not intend to misquote you, it was an error in the cut/paste on my part. I guess it is just your way of looking at things, I do not consider 5-10% a large percentage of all people.

My point in the management issues was not that there are no other differentials for the hypotensive elderly lady w/a AAA on U/S. However, the usefulness of the US is that it can augment a notoriously difficult physical exam. I do not disagree with you about the futility of PE on many of these patients.

Going back to your own quote from Sabiston, the patient you mentioned, afebrile septic hypotensive w/AAA on US does go to the OR, and not just by my book. In the treatment of that septic patient in the ED is IVF and Abx, maybe pressors and blood. But, if the AAA is the cause of the hypotension, tx'ing the sepsis will not help. I don't know this for a fact, but I would think that the interventions necessary for the septic patient can be done in the OR while the AAA is being repaired.

Your initial arguement was that US does not add to the managment of AAA in the majority of cases. I continue to disagree with you on this. The literature seems to argue that it does impact management.

 

[Docxter]

Originally posted by Coleman

Your initial arguement was that US does not add to the managment of AAA in the majority of cases. I continue to disagree with you on this. The literature seems to argue that it does impact management.

My point is that if the patient is stable (not in shock), I would get a CT as the definitive test (assuming no contraindications) before sending these patient to the OR to avoid false positive emergent operations. I'm defining false positive as aneurysm without leak or rupture. There is no question that the morbidity and mortality of emergent AAA surgery is much higher that elective repairs. Therefore, false positive emergent operations should be avoided as much as possible. Vascular surgeons agree (hence my quote from the textbook), that in stable patients, you get a CT. US will add relatively little in this context and just delay the CT.

The story is totally different in unstable patients and I agree with you guys that US has a role and the fact that you don't want to waste time for a CT in these unstable patients (that's what's also written in Sabiston's).

Obviously, the availability of CT is also a major factor. If you don't have it available immediately, well you don't have it and I, too, in that circumstance would do an US.

 

[roja]

I think an important, and perhaps obvious, point regarding all of this is that like the vast majority of things in emergency med is that there is not one and only awnser.

U/S and CT both are helpful in determining what to do with patietns.

A patient with a > 5-6cm AAA on U/Sand hypotension (especially if afebrile) should probably go to the OR without a CT. Because even if you CT is right next door, sending an unstable patient into the scanner is rarely a good idea.

However, a patient with abdominal pain and stable vitals with a AAA on U/S, CT might be a good idea.

I don't think using ONLY u/s or ONLY ct is every the right awnser.

not that anyone is advocating that....

 

[drpcb]

One caveat however, and I don't believe this has ever been evaluated prospectively, is that anyone with a ruptured or impending rupture probably should be ultrasounded gingerly to prevent iatrogenically induced worsening of the status. Inexperienced bedside sonographers may be more inclined to do this, even though the abdomen, unlike scanning through the intercostals is less likely to require a strong downward pressure.

 

[drpcb]

.I'm defining false positive as aneurysm without leak or rupture. There is no question that the morbidity and mortality of emergent AAA surgery is much higher that elective repairs. Therefore, false positive emergent operations should be avoided as much as possible.
Presumedly the main reason morbidity and mortality of emergent repairs is higher than elective ones is that the patient is already dying. I don't believe that simply labelling an unruptured aneurysm "emergent" is likely to increase the M&M of if the same surgery had been labeled "elective." Furthermore, I suspect a prudent surgeon doing an emergent ex lap at 3 am and finding an unleaking, unruptured aneurysm would close it up and repair it electively when the circumstances were more ideal

 

[Daniel vD]

Originally posted by Docxter
Great pickup on the US. However, be aware that you were extremely lucky that you saw the dissection. US has very poor sensitivity in detecting aortic dissection. Some would even argue that if a CT is immediately available, you should not waste the patient's precious time doing an ultrasound if you have a high suspicion of dissection. If CT is not immediately available, well, that's a different story. I have seen more than one patient code and die while people were futsing around in the ER trying to US the aorta.

The same goes for suspected AAA rupture. If the patient presents with Sx of AAA rupture, don't waste time with the US. Get the stat CT. One of our ER attendings was sued (had to eventually settle) in a case that he wanted an US to r/o AAA rupture instead of getting a stat CT. Most of the time the leak is retroperitoneal and you won't see much on US. Also, often you can't visualize the entire legth of the aorta and proximal common iliacs behind bowel gas. I have seen people miss a AAA since they saw the IVC which was of normal caliber. While US is great for detection and follow-up of AAA size, it's not that useful at all in acute cases of suspected rupture, especially if the patient is known to have AAA. Suppose you see a big aorta on US, so what?? You still couldn't exclude a leak. While US is a great tool, not using it appropriately can be very damaging to the management of patients.

As spyperdoc already said, you can get a quick U/S in 30 sec, while getting a CT takes quite long. And if this persons AA(A) is actually ruptured (and he isn't dead yet) you won't have 20 minutes to spend on a CT. You may have just enough time to get a U/S to confirm your suspicions and OFF TO THE F*CKING OR.
(If the patient is still alive, which I doubt anyway.)

 

[drpcb]

I read this link with you guys going around and around. I couldn't argue with the minority who had stat CT available within 15 minutes that it probably didn't make much of a difference. In our facility a stat CT takes approximately 60 minutes to be resulted and viewable.

The VERY SAME DAY that I read this link (night shift actually), I attended to a 76 year old woman whose nursing note said "syncope x 3, flank pain radiating down both legs. BP 152/74, HR 88." She had waited in triage for 2 hours or so before I saw her.

Of course the history was suggestive of AAA, and I was shocked when I palpated a large NONPULSATILE mass in the area of her aorta. She would complain of intermittent, sharp severe pains in the low back. The mass actually felt like a bladder or uterus, more than a AAA. An immediate bedside us clarified: at the maximum measurement she had a 5 cm lumen with a 9 cm Aorta. I could not tell if the 4 cm was intraluminal clot or extraluminal hematoma.


I contacted surgery consult, whose typically inappropriately nonchalant intern or 2nd year told me r/o AAA, get a CT scan. I didn't think this guy understood the acuity, so I contacted the chief vascular resident immediately as well. When I told him the history and my us findings he said "I will come in immediately, I will be there in 25 minutes." I was so impressed with his response I even decided to zip her up to CT while he was enroute.

CT confirmed a giant AAA, surrounded by a large hematoma. I pushed her up to the OR with a surgery resident, and she coded right as we arrived in the OR and were transferring her to the bed. I ran the code until anesthesia kicked me out, I figured I didn't want to hinder anything, so I left immediately. The surgeon splashed and sliced her to reveal a retroperitoneal exsanguination, cross clamped her aorta, grafted, but couldn't get her to tolerate the unclamping and she died after 2 hours in the OR.

The delay to OR from my seeing her was barely an hour. I am thrilled with the course of this case, if not the outcome. My ultrasound in this extremely critical case got the vascular surgeon into the hospital emergently before CT, and for this alone I am extremely happy with bedside US.

How can I post the images?