background

• To diagnose the underlying cause in a shocked

patient in a timely manner is vital as the
treatment options may be completely
different and also time critical
• It is imperative for emergency physicians to
equip themselves with ultrasound skills as it
can play a key role in the patien’s
management
Ultrasound scan can show a significant left ventricle wall motion abnormality
and explained the patient’s condition than ECG and X-ray
 case presentation
• a 60-year-old man who was brought to the emergency
department (ED) by paramedics after a sudden onset
of shortness of breath. On scene when attended by
the paramedics the patient was in significant
respiratory distress and was diaphoretic. There was
no history of chest pain. On arrival to the ED, he was
unresponsive but the airway was patent. The
patient’s breathing effort was very poor and he was
gasping. His trachea was central and chest was
completely silent. His breathing was supported
initially with a bag valve mask and then subsequently
the patient was intubated in view of his low Glasgow
Coma Scale (GCS).
He was easy to ventilate and the chest movements
were bilateral and equal. His first blood pressure
reading was 170/110 mm Hg and pulse rate was
about 120/min. His neck veins were not engorged
and he had equal blood pressure in both arms. His
GCS was 6/15 (E=1, V=1, M=4). The rest of the
examination was unremarkable. We could not
figure out the cause of the patient’s acute
deterioration after completing the primary survey.
The patient was continuously monitored and serial
ECGs were carried out. The ECGs were discussed
with the Cardiology Registrar who was not
convinced of any acute cardiac event. The patient
had no significant medical or surgical history and
was not on any medications.
 investigation
• Routine bloods in the ED were:
▸Haemoglobin 158 g/L (N=138 to 172 g/L)
▸ White cell count 17.1×109/L (N= 4.5-11 x 109 cells/L)
▸ Sodium 136 mmol/L (N= 136 and 145 mmol/L)
▸ Potassium 4 mmol/L (N= 3.6 to 5.2 mmol/L)
▸ Urea 6.1 mmol/L (N=3.0 – 9.2 mmol/L)
▸ Creatinine 97 μmol/L (N= 62– 115 µmol/L)
▸ Estimated glomerular filtration rate 73 mL/min/ L.73
m2 (N=less than 60 mL/min/1.73 m2 )
▸ C reactive protein <5 mg/L (N= less than 10 mg/L)
▸ Troponin I 115 μg/L (N= < 0.03 µg/L)
▸ International normalised ratio 1.0
▸ D-dimer 0.95 μg/L (N=< 0.5 μg/L )
▸ Arterial blood gas: pH 6.98, pCO2 16.02 kPa, pO2 21.7
kPa, HCO3 27.8 mmol/L, base excess −7.5, lactate 2.7.
CXR showed no significant pathology.
ECG showed sinus tachycardia with left ventricular
hypertrophy.
• cardiac ultrasound scan and shock scan conducted by
the ED Registrar showed global hypokinesia of the left
ventricle.
• Official echo performed later by the cardiologist
showed severe systolic dysfunction and apical
thrombus.
• The coronary angiogram revealed severe ostial
stenosis of the left main coronary artery.
 dd
• A patient with low GCS, shortness of breath
and type-2 respiratory failure may have wide
differentials like life-threatening asthma,
tension pneumothorax, acute cardiac events
or massive pulmonary embolism.
• An early shock scan using ultrasound helped
us narrow our differential towards a cardiac
pathology.