ddxof: POCUS for Undifferentiated Shortness of Breath
Undifferentiated Shortness of Breath
This is a co-post with our FOAMEd partner The ddxof - project of Dr. Tom Fadial . ddxof: is a compilation of cases based on real patients, each inspiring an algorithm for the evaluation and management of their chief complaint or diagnosis.
If you have any ideas for collaborating with our team don't hesitate to reach out.
Please see the original post here https://ddxof.com/ultrasound-in-dyspnea/
This is a common emergency department scenario: a critically-ill patient with undifferentiated dyspnea. The physical exam can be difficult and indeterminate with huge risks of deterioration. Our CHF patients often have COPD, afib and maybe renal failure. Your decisions matter. Here is a proposed approach for these patients.
Algorithm for the Use of Ultrasound in the Evaluation of Dyspnea
RUQ scan with large R pleural effusion. Spine sign+ (clear view of several thoracic vertebrae through the effusion)
This 80 year old male with a history of Alzheimer's with recent accelerated decline experienced a fall from bed. Though the only visible trauma involved a laceration above the right eye, globally diminished breath sounds were noted, and a prehospital eFAST exam was performed. Pictured is a large, right-sided pleural effusion, with visible spine sign observed during the exam. No other abnormalities were observed.
With the absence of significant chest trauma, the effusion was assumed to be non-traumatic in origin. Due to the patient's recent rapid decline, family elected to manage conservatively, and the patient was admitted to palliative care.
- Tom Hudson, NRP, CCP-C (Richmond Volunteer Rescue Squad)
25 y/o female in and MVA with hypotension, hypoxia.
Normal lung with A lines can briefly be seen until the sonographer moves the probe superiorly to reveal and area of B lines adjacent to A line.
In the setting of trauma this is consistent with Pulmonary Contusion.
Images: Dr. Catharine Bon - Kings County Hospital Emergency Medicine
This is a clip of an elderly gentleman, who was called as a respiratory distress code while walking to clinic without his home oxygen. Initially, patient was tachycardic, tachypnic, and hypoxic to mid 80s on RA, however normotensive in mild respiratory distress, resolved with 3L O2 by nasal canula.
This clip here was obtained by having the patient in the upright position, with the probe in the left lung base. You can see the diaphragm on the left side of the clip, with multiple loculated pleural effusions in left lung base adjacent to compressive atelectasis vs cardiac activity.
The effusion was later drained, found to be a malignant effusion, with a subsequent biopsy showing a Non-Small Cell CA in the left upper lobe and Squamous Cell CA in the right upper lung.
Chris Hanuscin, MD and John F. Kilpatrick, MD
Normal lung demonstrating the "lung curtain." As the patient takes a deep breath, the "dirty shadowing" of a normal air-filled lung comes over the liver like a curtain.
Dr. Gordon Johnson
WCUME 2017 Submission for "Creative Caption"
"In these days of violent extremist and warmongers, can it be a a good omen to find a dove flying in the pleural fluid?"
Marco Garrone, MD - Torino, Italy
WCUME 2017 Submission for "Best POCUS"
An acutely dyspnoeic patient presents with ventricular tachycardia and has no response to initial chemical cardioversion. Lung POCUS shows widespread bilateral confluent B lines indicating acute pulmonary edema. Unstable tachycardia terminated using synchronized electrical cardioversion.
Dr. Cian McDermott - Dublin, Ireland
The clip was captured in rural Uganda on a patient who presented for weight loss, night sweats, and cough. Utilizing the high-frequency, linear transducer the patient’s thoracic pleura and superficial lung were evaluated. The ultrasound demonstrated multiple focal sub-pleural lesions with tripartite B-lines consistent with miliary tuberculosis.
Michael Schick DO, MA
Emergency Medicine Physician
To assess for lung slide, look between two ribs. The two layers of pleura can be seen as the hyperechoic, shimmering line just under the subcutaneous tissue. This represents the sliding of the parietal and visceral pleura.
Normal lung slide should have:
Shimmering aka "ants marching"
This may be augmented by m-mode as pictured in another post.
Dr. Matthew Riscinti - Kings County Emergency Medicine
46 y/o M with 20 pack year smoking history with sudden onset right sided chest pain that woke him from sleep. Decreased breath sounds on right side. POCUS with decreased lung slide (right of image) with normal lung slide in left lung (left side of image).
Lung slide can often be appreciated by watching the pleural surfaces move along each other but if you're uncertain, putting the US in m-mode and looking for the classic "seashore sign" (left image) versus the "barcode sign" (right image) can help you figure it out.
Dr. Eric Roseman - Resident Physician, Kings County Emergency/Internal Medicine