Anesthesia: Essays and Researches  Login  | Users Online: 430 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Home | About us | Editorial board | Ahead of print | Search | Current Issue | Archives | Submit article | Instructions | Copyright form | Subscribe | Advertise | Contacts


 
Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 13  |  Issue : 4  |  Page : 695-698  

Utility of point-of-care ultrasonography in diagnosing submassive pulmonary thromboembolism in a trauma patient and subsequent anesthetic management: case report and literature review


Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission25-Aug-2019
Date of Decision09-Sep-2019
Date of Acceptance14-Nov-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Nitika Goel
Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, HN0-165, Sector 15 A, Chandigarh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_120_19

Rights and Permissions
   Abstract 

Point-of-care ultrasonography is defined as ultrasonography brought to the patient's bedside and performed by the provider in real time. The clinician can use these real-time dynamic images immediately (rather than images recorded by a sonographer and interpreted later), allowing findings to be directly correlated with the patient's presenting signs and symptoms. Point-of-care ultrasonography is easily repeatable if the patient's condition changes. Over the past decade, the use of point-of-care ultrasonography has extended to emergency settings and intensive care units. The role of ultrasound in triage patients is not only limited to the Focused Assessment with Sonography for Trauma which includes assessment for hemoperitoneum and hemopericardium, it has also been used to detect the presence of hemothorax, pneumothorax, and intravascular filling status in a trauma patient. However, the use of ultrasonography in detecting pulmonary thromboembolism in trauma has not been commonly reported. We report a patient in whom submassive pulmonary embolism was detected by lung ultrasound and thereafter operated for bilateral open Grade III lower-limb fractures. The surgery was proceeded under bilateral ultrasound-guided femoral sciatic nerve block.

Keywords: Femoral sciatic nerve block, pulmonary embolism, trauma, ultrasonography


How to cite this article:
Goel N, Jain K, Dhiman D, Gowtham K. Utility of point-of-care ultrasonography in diagnosing submassive pulmonary thromboembolism in a trauma patient and subsequent anesthetic management: case report and literature review. Anesth Essays Res 2019;13:695-8

How to cite this URL:
Goel N, Jain K, Dhiman D, Gowtham K. Utility of point-of-care ultrasonography in diagnosing submassive pulmonary thromboembolism in a trauma patient and subsequent anesthetic management: case report and literature review. Anesth Essays Res [serial online] 2019 [cited 2020 Jan 24];13:695-8. Available from: http://www.aeronline.org/text.asp?2019/13/4/695/272968


   Introduction Top


Prehospital point-of-care ultrasound (POCUS) is revolutionizing the care of trauma victims, especially when applied in emergency settings. The role of ultrasound in triage patients is not only limited to the Focused Assessment with Sonography for Trauma (FAST) which includes assessment for hemoperitoneum and hemopericardium, but it has also been used to detect the presence of hemothorax, pneumothorax, and intravascular filling status (E-FAST).[1] The diagnosis of pulmonary embolism (PE) is often more troublesome in emergency settings, particularly when considered as a cause of sudden circulatory failure (so-called “massive” PE). For these unstable patients, the hazard of transportation to the computed tomography (CT) scanner in order to exclude PE is not insignificant. Furthermore, it may not be possible in patients with known allergy to contrast media, severe renal insufficiency, and pregnant women[2] to undergo CT pulmonary angiography (CTPA) for early detection of PE. In such settings, POCUS has proved to be a valuable alternative diagnostic tool. We report the utility of point-of-care ultrasonography in successfully diagnosing submassive pulmonary thromboembolism in a triage patient and subsequent anesthetic management for bilateral open Grade IIIB lower-limb fractures.


   Case Report Top


The consent of the patient was obtained before publishing this report. A 35-year-old male, weighing 86 kg, presented with multiple fractures of bilateral upper and lower limbs following road traffic accident. On examination, he was fully conscious, cooperative having respiratory rate of 38 breaths per minute, heart rate 104 beats per minute and blood pressure 142/76 mm of Hg in supine position. His room air saturation was 85% which increased to 100% on ventimask having FiO2 of 0.6. On auscultation, fine crackles were present in bilateral lung fields. His routine blood investigations showed hemoglobin – 8 g/dL, platelet count – 1.3 lakhs, and total lymphocyte count – 8800 μL − 1, and room air arterial blood gas (ABG) showed pH – 7.408, PaO2– 48.5 mmHg, PCO2– 34.3 mmHg, HCO3– 21.2 mEq/L, and Base excess – −2.7. Upper and lower limb roentgenograms revealed a closed fracture of left shaft of the humerus and open grade IIIB fractures of left both bone leg and right fourth and fifth metatarsals. Chest roentgenogram showed patchy areas of consolidation throughout the right lung fields and left upper lobe [Figure 1].
Figure 1: Chest X-ray of a patient at presentation. Patchy areas of consolidation seen throughout the right lung and left upper zone

Click here to view


Lung ultrasonography was done according to the SLESS protocol (six-field evaluation).[3] An “A” pattern was observed on all left lung fields, while on the right lung, an “A” pattern was observed on the apex, but some “B-” lines were seen in the anterior part of the lung base, and small subpleural consolidation was seen in more posterior position [Figure 2], thus raising suspicion of PE. Therefore, urgent CTPA was advised which confirmed the presence of pulmonary thromboembolism [Figure 3]. A plain CT scan of the brain showed tentorial subdural hemorrhage and left basal ganglia contusion which required conservative management.
Figure 2: Lung ultrasonography picture of the patient showing subpleural consolidation (marked with red arrows) P- Pleura C - Costal shadow

Click here to view
Figure 3: Computed tomography pulmonary angiography – Mediastinal window showing multiple filling defects in branches of the right pulmonary artery

Click here to view


Since the fractures required immediate fixation in view of their complex nature, it was decided to proceed the surgery under bilateral ultrasound-guided femoral sciatic nerve block. Ultrasound-guided bilateral sciatic nerve blocks were administered through popliteal approach.[4] Following individual sciatic nerve blocks, femoral nerve blocks were also given. Fifteen minutes following the second block, after confirming loss of temperature sensation up to L2 level, the surgery was started. Supplemental O2 administered through a venturi mask with FiO2 of 0.6 maintained a SpO2 of 92%. Intraoperative hemodynamics remained within normal limits. However, the respiratory rate varied between 26 and 30 breaths per minute. Intraoperative ABG showed pH – 7.4, PaO2– 135.7 mmHg, PCO2– 33.8 mmHg, HCO3– 20.4 mEq/L, and BE – −3.6 on FiO2 of 0.6. The surgery was completed uneventfully in 1 h 30 min. Six hours postsurgery, injection Clexane 0.6 mg.kg-1 twice daily was started. He was also started on tablet warfarin 4 mg once daily till international normalized ratio (INR) of 2 was achieved. Following INR of 2, injection Clexane was stopped, and the patient was discharged in stable condition.


   Discussion Top


Pulmonary thromboembolism is responsible for 200,000–300,000 hospital admissions worldwide every year.[5] Despite decades of research on PE, the diagnosis remains elusive in many situations, and the fatality rate remains significant.[5] PE can present with a multitude of complaints, and it is essential to keep a low threshold when deciding to include it in the differential. The availability of compact ultrasound machines helps in establishing early differential diagnosis of PE, which guides the further course of investigations and subsequent management.

Literature shows various case reports documenting the use of POCUS for early diagnosis of lung contusion and acute respiratory distress syndrome in blunt trauma patients.[6] However, in polytrauma patients without any chest injuries presenting in acute hypoxemia, POCUS can help to diagnose certain occult causes including acute respiratory distress syndrome and PE. Peripheral parenchymal consolidations are visible on lung ultrasound when an embolic vascular occlusion occurs.[7] These consolidations are due either to necrosis of lung parenchyma (infarction) or to atelectasis, related to the breakdown of surfactant with extravasation of blood.[7] The presence of A profile on lung ultrasonography with few subpleural consolidations is diagnostic of PE.[7] B-lines are usually absent or <3 in PE [Figure 4] and [Figure 5].[8]
Figure 4: Lung ultrasonography showing multiple A-lines P- Pleura C - Costal shadow

Click here to view
Figure 5: Lung ultrasonography showing multiple B-lines P- Pleura C - Costal shadow

Click here to view


A recent systematic review of accuracy test studies of lung US for the diagnosis of PE in patients with clinical suspicion of PE has demonstrated a sensitivity of 87.0% and a specificity of 81.8% when this technique was used as a single test.[9] The use of triple point-of-care ultrasonography which includes a combination of echocardiography, compressive leg ultrasonography, and lung ultrasonography has been found to increase the sensitivity and specificity to 90% and 86.2% in diagnosing PE.[10] In our patient, lung ultrasonography demonstrated A profile in most of the lung scans with areas of subpleural consolidation seen in the right lung, which leads to suspicion of PE. We chose to undergo CTPA as it was feasible to do it on emergency basis in our hospital.

Our case report highlights the potential use of point-of-care ultrasonography in making early diagnosis of PE. This not only avoids unnecessary delay in establishing differential diagnosis but also guides the further management course in patients, especially those presenting to emergency department with unstable hemodynamics. Thus, we conclude that POCUS is a highly promising modality for diagnosing occult abnormalities such as PE in the emergency department. Although POCUS has become a common modality these days, its application for diagnosing PE in triage settings has rarely been reported. Therefore, in the presence of limitations to CTPA, POCUS and recently triple POCUS can provide alternate diagnostic strategies for PE.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Rippey JC, Royse AG. Ultrasound in trauma. Best Pract Res Clin Anaesthesiol 2009;23:343-62.  Back to cited text no. 1
    
2.
Squizzato A, Galli L, Gerdes VE. Point-of-care ultrasound in the diagnosis of pulmonary embolism. Crit Ultrasound J 2015;7:7.  Back to cited text no. 2
    
3.
Santos TM, Franci D, Coutinho CM, Ribeiro DL, Schweller M, Matos-Souza JR, et al. A simplified ultrasound-based edema score to assess lung injury and clinical severity in septic patients. Am J Emerg Med 2013;31:1656-60.  Back to cited text no. 3
    
4.
Karaarslan S, Tekgül ZT, Şimşek E, Turan M, Karaman Y, Kaya A, et al. Comparison between ultrasonography-guided popliteal sciatic nerve block and spinal anesthesia for hallux valgus repair. Foot Ankle Int 2016;37:85-9.  Back to cited text no. 4
    
5.
Church A, Tichauer M. The emergency medicine approach to the evaluation and treatment of pulmonary embolism. Emerg Med Pract 2012;14:1-22.  Back to cited text no. 5
    
6.
Leblanc D, Bouvet C, Degiovanni F, Nedelcu C, Bouhours G, Rineau E, et al. Early lung ultrasonography predicts the occurrence of acute respiratory distress syndrome in blunt trauma patients. Intensive Care Med 2014;40:1468-74.  Back to cited text no. 6
    
7.
Mathis G, Blank W, Reissig A, Lechleitner P, Reuss J, Schuler A, et al. Thoracic ultrasound for diagnosing pulmonary embolism: A prospective multicenter study of 352 patients. Chest 2005;128:1531-8.  Back to cited text no. 7
    
8.
Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, et al. Lung B-line artefacts and their use. J Thorac Dis 2016;8:1356-65.  Back to cited text no. 8
    
9.
Squizzato A, Rancan E, Dentali F, Bonzini M, Guasti L, Steidl L, et al. Diagnostic accuracy of lung ultrasound for pulmonary embolism: A systematic review and meta-analysis. J Thromb Haemost 2013;11:1269-78.  Back to cited text no. 9
    
10.
Nazerian P, Vanni S, Volpicelli G, Gigli C, Zanobetti M, Bartolucci M, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014;145:950-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed60    
    Printed0    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal