Cardiogenic pulmonary edema (ultrasound)
Progressive dyspnea on exertion.
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Lungs: sliding present bilaterally, visceral-parietal pleural interface regular, symmetric and innumerable B-lines anteriorly.
Parasternal long axis: septum/posteroinferior wall severely hypokinetic, wall thickening markedly reduced, E-point septal separation >2cm (normal <7mm), no apparent pericardial fluid.
Subcostal vena cava: junction with right atrium visualized in long axis, IVC plethoric with minimal respirophasic variability, hepatic veins distended.
Point‐of‐care echocardiography is often integrated into the emergency evaluation of undifferentiated presentations suspected to have a cardiopulmonary etiology5.
Designed to assess the presence or absence of common hemodynamic patterns encountered in the critically ill, a limited examination of the lungs often serves as a surrogate for left atrial pressure if signs of elevated filling pressures are present. Assessment of the IVC serves as a rough correlate of RAP.2
Presenting with progressive dyspnea on exertion, the patient in question was examined with the following questions:
- what is the global (qualitative) left ventricular function?
- is there any obvious pathology e.g. effusion, septal bowing, dissection flap?
- what are the chamber dimensions and wall thickness?
In this context (clinical suspicion for CHF), the findings of depressed wall movement and thickening, chamber dilation, extravascular lung water, and a dilated IVC are consistent with the presence of poor forward flow, cardiac remodelling, elevated pulmonary venous and capillary pressures, and volume overload,6 defining features of the heart failure syndrome (with prominent systolic dysfunction). Myocardial stiffness and relaxation are more laborious to approximate; with a preserved ejection fraction but findings consistent with heart failure, point of care echocardiography protocols often use increased wall thickness as supporting evidence of "diastolic'' dysfunction.6
- 1. McKaigney CJ, Krantz MJ, La Rocque CL, Hurst ND, Buchanan MS, Kendall JL. E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction. (2014) The American journal of emergency medicine. 32 (6): 493-7. doi:10.1016/j.ajem.2014.01.045 - Pubmed
- 2. Zhuang Y, Dai L, Chen M, Chang N, Chen J, Shi H. [Diagnostic value of lung ultrasound B-line score in acute heart failure]. (2018) Zhonghua wei zhong bing ji jiu yi xue. 30 (2): 156-159. doi:10.3760/cma.j.issn.2095-4352.2018.02.012 - Pubmed
- 3. Wang HK, Tsai MS, Chang JH, Wang TD, Chen WJ, Huang CH. Cardiac ultrasound helps for differentiating the causes of acute dyspnea with available B-type natriuretic peptide tests. (2010) The American journal of emergency medicine. 28 (9): 987-93. doi:10.1016/j.ajem.2009.05.019 - Pubmed
- 4. Blanco P, Aguiar FM, Blaivas M. Rapid Ultrasound in Shock (RUSH) Velocity-Time Integral: A Proposal to Expand the RUSH Protocol. (2015) Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. 34 (9): 1691-700. doi:10.7863/ultra.15.14.08059 - Pubmed
- 5. Bagheri-Hariri S, Yekesadat M, Farahmand S, Arbab M, Sedaghat M, Shahlafar N, Takzare A, Seyedhossieni-Davarani S, Nejati A. The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department. (2015) Emergency radiology. 22 (5): 517-20. doi:10.1007/s10140-015-1311-z - Pubmed
- 6. Wright J, Jarman R, Connolly J, Dissmann P. Echocardiography in the emergency department. (2009) Emergency medicine journal : EMJ. 26 (2): 82-6. doi:10.1136/emj.2008.058560 - Pubmed