Pitt IM POCUS

1. Shock, Respiratory Failure, and a
Chest X-ray
A Case Discussion of Clinical Reasoning and POCUS
Free Open-Access Medical Education in Point of Care
Ultrasound
Produced by Pitt IM POCUS

2. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?

3. Case info
70s f with ischemic CM, EF 30% p/w with acute resp failure and shock
Pt was well until 12 hrs ago when she began to feel short of breath with exertion. Progressed
to severe dyspnea at rest, with left sided chest pain, productive cough (pinkish sputum),
nausea/vomiting. She has been adherent to lasix and she is near her dry weight.
T 37.1 HR 140 BP 80/60 SpO2 84% RR 40 on BIPAP.
Crackles left lung. JVP not seen. 1+ LE edema b/l. Systolic murmur heard, hard to characterize
due to loud breathing. Intubated due to resp failure/hemodynamic instability. Requiring high
dose pressors. CXR shown in next slide.
Tn was 0.1. Unfortunately with intubation/induction, pt became pulseless (PEA). Was
successfully resuscitated with CPR and epi. The ultrasound machine then became helpful for
access and for quick diagnostics.

4. CXR

5. Case info
70s f with ischemic CM, EF 30% p/w with acute resp failure and shock
Pt was well until 12 hrs ago when she began to feel short of breath with exertion. Progressed
to severe dyspnea at rest, with left sided chest pain, productive cough (pinkish sputum),
nausea/vomiting. She has been adherent to lasix and she is near her dry weight.
T 37.1 HR 140 BP 80/60 SpO2 84% RR 40 on BIPAP.
Crackles left lung. JVP not seen. 1+ LE edema b/l. Systolic murmur heard, hard to characterize
due to loud breathing. Intubated due to resp failure/hemodynamic instability. Requiring high
dose pressors. CXR shown
Tn was 0.1. Unfortunately with intubation/induction, pt became pulseless (PEA). Was
successfully resuscitated with CPR and epi. The ultrasound machine then became helpful for
access and for quick diagnostics.
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?

6. Pause before POCUS
Let’s pause before obtaining POCUS images to think…
Pt is sick. With unilateral lung opacity. First thought ie Type 1 reasoning - PNA
But there's some discordance with PNA (no fever, unusual CXR appearance).
Type 2 reasoning kicks in
What about xray appearance?
1) Neither the heart border nor diaphragm is obscured
2) Seems to have "batwing" appearance, but just one side
3) Center appears dense/"alveolar" but periphery appears interstitial
4) R lung seems to have slight interstitial pattern

7. Pause before POCUS
What about xray appearance?
1) Neither the heart border nor diaphragm is obscured
2) Seems to have "batwing" appearance, but just one side
3) Center appears dense/"alveolar" but periphery appears interstitial
4) R lung seems to have slight interstitial pattern

8. Pause before POCUS
Pre-POCUS differential diagnosis
1) PNA
2) Acute MR
3) LV systolic failure
4) PE

9. Pause before POCUS
POCUS questions
Lung: are there B lines (and where)? Is there consolidation?
Heart: is there MR? (note limited use in POCUS, and not useful as negative - see
article. Is the RV dilated? (Note: EF expected to be reduced. IVC expected to be
dilated.)
DVT: are femoral veins compressible?

10. Pause before POCUS
You have decided to perform POCUS to answer your specific questions.
How will you approach the exam?
a) Take your time and do a good, thorough POCUS exam
b) Take a quick look to try to gather what data you can to answer your
questions

11. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?

12. Left Lung (L1)
• Interpretation?
• Limitations/Feedback on image quality
Right Lung (R1)

13. Koratla, 2019.
https://www.renalfellow.org/2019/03/27/basics-of-lung-ultrasound-for-the-nephrologist-what-are-a-lines-and-b-lines/
Reminder of Sonographic Lung Zones

14. Cardiac
• Interpretation?
• Limitations/Feedback on image quality

15. Cardiac
• Interpretation?
• Limitations/Feedback on image quality

16. POCUS interpretation
Point-of-Care Ultrasound
Performed MM/DD/YY
L lung: confluent B lines at apex
R lung: multiple B lines at apex
Heart: Reduced EF. Large MR jet seen. TR jet seen. RV not massively dilated.

17. POCUS interpretation
Here is a repeat CXR 1 hour later, to help understand the process by assessing radiographic
evolution

18. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?

19. Diagnostic and Management Discussion
What is going on?
What are the next steps in diagnosis and management?

20. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?

21. Hospital Course
• Initially seemed most likely PNA (vs MR).
• POCUS did reveal a very large MR jet (note: classifying severity is nuanced)
• In pt with already fair prob of acute MR, the POCUS findings further raised
that probability.
• The dx was felt to be acute MR, possibly due to papillary muscle rupture
• Hard to say for sure there is not PNA but seems less likely the primary process.

22. Questions/Learning Points
1) How can acute MR cause a unilateral lung opacity?
2) Why did POCUS reveal b/l pulmonary edema, while CXR only left sided
3) How useful is POCUS for mitral regurgitation?

23. 1) How can acute MR cause a unilateral lung opacity?
MR jet usually affects R upper
PV —> increase in PCWP on
the right side --> larger degree
of right-sided edema.
But in 11% of cases, affects L
lung only
http://www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-
ray-heart-failure.html

24. 2) Bilateral B-lines, but unilateral CXR opacity?
B-lines appear earlier than CXR opacities
A systematic review of diagnostic modalities for dx of acute heart failure
in ED sheds light on this...
Lung US has higher sensitivity vs CXR for identifying pulm edema
https://www.ncbi.nlm.nih.gov/pubmed/26910112

25. 2) Bilateral B-lines, but unilateral CXR opacity?
https://www.ncbi.nlm.nih.gov/pubmed/26910112

26. 2) Bilateral B-lines, but unilateral CXR opacity?
A study of IM/EM/Radiology residents also found better accuracy of Lung
US vs CXR for identifying pulmonary edema. Interestingly, confidence
was higher with CXR, though accuracy was higher with US
https://www.ncbi.nlm.nih.gov/pubmed/23263648

27. 2) Bilateral B-lines, but unilateral CXR opacity?
https://www.ncbi.nlm.nih.gov/pubmed/23263648

28. Note that POCUS (and even TTE) can underdiagnose MR, especially if the jet is
eccentric.
Don't be falsely reassured by a negative study. A markedly positive study, as in
this case, may be very helpful.
No data on POCUS for MR
3) POCUS and Mitral Regurgitation

29. Case wrap-up
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?

30. Take home points
• Ultrasound detects pulmonary edema sooner (i.e. at lower PCWP) than CXR
• When encountering a unilateral lung opacity on CXR, consider acute MR as a
possible etiology
• POCUS may not be very sensitive for detecting MR, but may be useful to
quickly identify a significant abnormality
• Some cases may call for a very quick and focused POCUS exam rather than
an extensive, thorough one

31. Want to dive deeper into this case, or see more cases?
This case was presented by Pitt IM POCUS on twitter in May 2019. Follow this
link to see the full thread, including comments and discussion from the POCUS
MedTwitter community. We thank the MedTwitter community for
contributions to this thread.
Please follow us at @PittIMPOCUS
Follow this link for other case presentations
Any questions, please contact
Michelle Fleshner – mfleshner301@gmail.com
Steve Fox – stevefox00@gmail.com

32. This is free, open access medical education. You may download, share, modify,
and use freely when used for medical education.
Patient confidentiality is the priority in these cases, so details may be left out
or modified to prevent identification. An effort is made to maintain the
educational quality.

33. References/Additional Reading
• CXR findings at varying PCWP thresholds (Radiology Assistant)
• Diagnosing Acute Heart Failure in the ED (Martindale, SAEM 2015)
• Diagnosing Pulmonary Edema: Lung US vs CXR (Martindale, EJEM 2013)