another reason why U/S rocks

[VentdependenT]

covering ccu last pm get consult at 10 by surg onc:

67M liver mass 5h s/p open cholecystectomy for gas in GB wall and obstructive jandice is intubated for hypoxia and now on neosynephrine 400ucg/min. afeb, HR 80, sbp drifting down to low 90's, spo2 97 peep5 fio2 1. surgery uneventful other than being dispo'd from pacu on 100% nrb because of spo2 86% on 5L nc.......nice

trops 1.6 without any obvious changes on EKG. CVP 25 in SICU. CVP intraop was 18-23. given 2L 5%albumin and 1L crystalloid. Zero UOP since end of case. here i stand.

Their attending wants swan. I recommend wean down neo while starting levophed. Swan goes in, HR drop to 40, sbp to 60. swan aborted.

I put US on, zero IVC variation on m-mode, IVC huge. Put US on chest, LV is doin NOTHING. RV barely moving but its still smaller than LV and septum not bulging into LV. I used focus exam. I ask to bring up dobuta and hook up flotrack. CI 2.1 on 25ucg/min levophed.

Anypoops we decided to add in dopamine and nix the dobuta. Started throwing multiform pvc singlets and dobuta was a scary prospect. Echo tech rolls in for formal exam, EF<10%, global rv/lv hypokinesis with preservation of LV apex. Next trop 3.6 w/o ekg change. ?stress induced cardiomyopathy vs large posterior infarct.

Point is US is the bomb and its not hard to learn basic views. Takes guess work out of interpreting static numbers. Practice practice practice.

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[redy]

Kind of similar situation.

20 something male h/o heroin abuse presents with leukocytosis and BP in 60s/40s. ICU being consulted for septic shock. ICU attending sees patient cold and clammy, doubts sepsis, puts probe on chest sees EF of 5%. Patient to CCU for cardiogenic shock secondary to viral myocarditis. Kid gets better in 2 days. DCed in a week.

 

[redy]

double post

 

[glorfindel]

Yeah, it's really the bomb. The whole field of EM is in love with ultrasound now.

I'm still baffled when I see an ICU without an US machine of their own - this means ICU people keep stealing my US machine from the ER on a regular basis. Which is exactly what I would do if I were in the unit.

 

[Bostonredsox]

Yeah, it's really the bomb. The whole field of EM is in love with ultrasound now.

I'm still baffled when I see an ICU without an US machine of their own - this means ICU people keep stealing my US machine from the ER on a regular basis. Which is exactly what I would do if I were in the unit.

Your welcome.

 

[nlax30]

Luckily our ED got a new unit so we kind of inherited their old portable US for resident/unit use.

I would definitely like to become more proficient with it, definitely comfortable using it for lines, but would like to use it more for getting some cardiac views as well as IVC variation and optic nerve sheath for increased ICP (reading some on that lately as we do a good bit of neurosurg cases).

Had a septic shock case over the weekend where the pt had just diffuse chronic anasarca to the point that we couldn't get a pulse or BP. Used US for the first time to get an arterial line in after RT failed to even get a gas after numerous attempts. Actually worked pretty well.

Our cardio fellows got one of those handheld pocket US devices that they can bring to a code if needed. Already used it a couple times to find a large effusion that needed tapping.

 

[VentJockey]

Yeah, ultrasound adds a heck of a lot more certainty to almost any situation. I really, really love it. I'm hoping to learn as much as I can about it during my IM residency. Anyone have suggestions on good learning materials?

 

[Bostonredsox]

Yeah, ultrasound adds a heck of a lot more certainty to almost any situation. I really, really love it. I'm hoping to learn as much as I can about it during my IM residency. Anyone have suggestions on good learning materials?

Practice. you can read all the books and diagrams you want. You need to get your shops machine every chance you get for every possible procedure you can use it for. Then play around with it. Try different views, depths, get to know your shops machine well. That is what I have done. And I occasionally grab the CV surgeon when hes floating around and say hey can you explain this not sure what i am looking at? Has paid me dividends greatly. And I am also IM.

 

[VentdependenT]

I also hang with the echo techs when I have some down time on a rotation. Has helped me greatly. Also with IR guys for their US guided procedures. Sonosite has an app. Also recommend Focus Pocket Guide App for echos. Pricey but worth it. US all your patients lungs, IVCs, and tickers in the unit. Practice!