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Fulltext Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade

Adi O, Ahmad AH, Fong CP, Ranga A, Panebianco N

Ultrasound J, 2021 Apr 15;13(1):22.
PMID: 33856577 DOI: 10.1186/s13089-021-00225-7

BACKGROUND: Pericardial effusion is a known complication of post-open cardiac surgery which can progress to life-threatening cardiac tamponade. Classical signs of tamponade such as hypotension and pulsus paradoxus are often absent. Diagnosing acute cardiac tamponade with transthoracic echocardiography (TTE) can be challenging in post-cardiac surgical patients due to distorted anatomy and limited scanning windows by the presence of surgical dressings or scar. Additionally, this patient population is more likely to have a loculated pericardial effusion, or an effusion that is isoechoic in appearance secondary to clotted blood. These findings can be challenging to visualize with traditional TTE. Missed diagnosis of cardiac tamponade due to loculated pericardial clot can result in delayed diagnosis and clinical management.
CASE PRESENTATION: We report a case series that illustrates the diagnostic challenge and value of resuscitative transesophageal echocardiography (TEE) in the emergency department (ED) for the diagnosis of cardiac tamponade due to posterior loculated pericardial clot in post-surgical coronary artery bypass graft (CABG) patients.
CONCLUSIONS: Cardiac tamponade due to loculated posterior pericardial clot post-CABG requires prompt diagnosis and appropriate management to avoid the potential for hemodynamic instability. Transesophageal echocardiography allows a rapid diagnosis, early appropriate referral and an opportunity to institute appropriate therapeutic measures.
Fulltext Novel role of focused airway ultrasound in early airway assessment of suspected laryngeal trauma

Adi O, Sum KM, Ahmad AH, Wahab MA, Neri L, Panebianco N

Ultrasound J, 2020 Aug 12;12(1):37.
PMID: 32783133 DOI: 10.1186/s13089-020-00186-3

BACKGROUND: Upper airway injury secondary to blunt neck trauma can lead to upper airway obstruction and potentially cause a life-threatening condition. The most important aspect in the care of laryngeal trauma is to establish a secure airway. Focused airway ultrasound enables recognition of important upper airway structures, offers early opportunity to identify life-threatening upper airway injury, and allows assessment of the extent of injury. This information that can be obtained rapidly at the bedside has the potential to facilitate rapid intervention.
CASE PRESENTATION: We report a case series that illustrate the diagnostic value of focused airway ultrasound in the diagnosis of laryngeal trauma in patients presenting with blunt neck injury.
CONCLUSION: Early recognition, appropriate triaging, accurate airway evaluation, and prompt management of such injuries are essential. In this case series, we introduce the potential role of focused airway ultrasound in suspected laryngeal trauma, and the correlation of these exam findings with that of computed tomography (CT) scanning, based on the Schaefer classification of laryngeal injury.
Pericardial decompression syndrome: A complication of pericardiocentesis

Adi O, Fong CP, Ahmad AH, Azil A, Ranga A, Panebianco N

Am J Emerg Med, 2021 07;45:688.e3-688.e7.
PMID: 33514476 DOI: 10.1016/j.ajem.2021.01.022

Pericardial Decompression Syndrome (PDS) is an uncommon but life-threatening complication following pericardiocentesis for cardiac tamponade. We report PDS after pericardiocentesis in two patients that presented to the emergency department with cardiac tamponade. In both cases, pericardiocentesis was performed under ultrasound guidance using the left parasternal approach and approximately 1200-1500 mL of pericardial fluid was removed. Immediately after pericardiocentesis, the haemodynamic status of the patients improved. However, 2-3 h post decompression, both patients developed hypotension and pulmonary edema with reduced left ventricular function, suggestive of PDS. PDS is a condition that is described as paradoxical worsening of vital signs after successful decompression of the pericardium in the setting of acute tamponade. Three possible mechanisms explaining PDS are ischaemic, hemodynamic and autonomic processes. If PDS is unrecognized and untreated, it is associated with a high mortality rate secondary to pulmonary edema and cardiogenic shock. If managed urgently, the cardiopulmonary dysfunction in PDS is usually transient and largely reversible with supportive care.
Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department

Osman A, Fong CP, Wahab SFA, Panebianco N, Teran F

J Emerg Med, 2020 Sep;59(3):418-423.
PMID: 32591302 DOI: 10.1016/j.jemermed.2020.05.003

BACKGROUND: Although surface sonography has become an essential diagnostic tool in the evaluation of trauma patients, important limitations of this modality include the evaluation of retroperitoneal hemorrhage and mediastinal pathology, such as blunt traumatic aortic injuries (BTAI). As in other emergency applications where surface sonography can't provide the information needed, focused transesophageal echocardiography (TEE) may represent a valuable diagnostic tool in the evaluation of hemodynamically unstable trauma patients with suspected thoracic pathology such as BTAI.
CASE SERIES: We present a series of five cases that illustrate the diagnostic value of emergency physician-performed resuscitative TEE in the diagnosis of BTAI in patients presenting with blunt thoracic trauma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As the use of point-of-care TEE during resuscitation continues to expand in emergency medicine, the evaluation of patients with BTAI represents a novel application where this emerging modality can allow early diagnosis of these injuries in hemodynamically unstable patients.
Shock due to superior vena cava obstruction detected with point of care ultrasound

Adi O, Ahmad AH, Fong CP, Hamid ZA, Panebianco N

Am J Emerg Med, 2021 Oct;48:374.e1-374.e3.
PMID: 33773866 DOI: 10.1016/j.ajem.2021.03.032

Superior Vena Cava (SVC) syndrome is caused by SVC obstruction by external compression or intraluminal thrombus. Patients with the condition can present with upper body swelling, shortness of breath and shock. This case report highlights the use of point-of-care ultrasound (POCUS) to evaluate a patient with SVC syndrome in the emergency department. The test offers many advantages over computed tomography (CT), venography, and magnetic resonance imaging which are limited in hemodynamically unstable patients. A 60-year-old male presented with acute respiratory distress and shock. The POCUS showed the presence of a right lung consolidation and SVC thrombus. CT revealed the presence of a large mediastinal mass causing compression of the SVC with clot seen inside the vessel. The patient was thrombolysed with intravenous streptokinase and his hemodynamics improved. Further investigation confirmed the diagnosis of lymphoma. The SVC can be visualized with transthoracic echocardiography using either the suprasternal, right supraclavicular or right parasternal approach. In this case, the presence of consolidation of the right lung mass provided an acoustic window for the visualization of the SVC using the right parasternal view, thereby allowing for more rapid diagnosis and management.
Hypotensive patient with superior vena cava obstruction diagnosed using resuscitative transesophageal echocardiography

Adi O, Apoo FN, Fong CP, Ahmad AH, Panebianco N

Am J Emerg Med, 2023 Oct;72:224.e1-224.e4.
PMID: 37500381 DOI: 10.1016/j.ajem.2023.07.037

BACKGROUND: Superior vena cava syndrome (SVCS) is a malignancy-related emergency. It is caused by obstruction of blood flow in the superior vena cava (SVC) secondary to intraluminal thrombosis, external compression, or direct invasion of tumor.
CASE SUMMARY: A 49-year-old male presented to the emergency department (ED) with acute hypoxemic respiratory failure. He was intubated and treated as pneumonia. Post-intubation, he became hypotensive, requiring fluid resuscitation and inotropic support. Resuscitative transesophageal echocardiography (TEE) showed external compression by a lung mass and an intraluminal thrombus causing SVC obstruction. Computed tomography (CT) angiography was performed, and it confirmed the TEE findings. A provisional diagnosis of lung carcinoma was made, and he underwent endovascular therapy for rapid symptomatic relief.
DISCUSSION: This case report highlights the role of resuscitative TEE in evaluating a hypotensive patient with clinical suspicion of SVCS at the emergency department. TEE performed at the bedside could help to diagnose and demonstrate the pathology causing SVCS in this case. TEE allowed high-quality image acquisition and was able to overcome the limitation of transthoracic echocardiography (TTE). TEE should be considered as an alternative ED imaging modality in the management of SVCS.
Abstracts from the 13th WINFOCUS World Congress on Ultrasound in Emergency & Critical Care

Alerhand S, Nevel A, Nelson B, Halperin M, Serrano F, Prosen G, et al.

Crit Ultrasound J, 2017 Dec 21;9(Suppl 1):26.
PMID: 29270697 DOI: 10.1186/s13089-017-0082-z