Paramedics bring in a 60-year-old male who collapsed at work and remained unresponsive. They state that there was bystander CPR and a lot of freaking out by coworkers. The only past history they have was from a coworker who thought he had high blood pressure. There was also a witness who told them he was just walking, then doubled over and collapsed without saying a thing. No one knew if he had any symptoms earlier in the day. Paramedics state he was initially in a PEA rhythm at a rate of 120 bpm on the monitor. They started an IV, gave him a 500cc saline bolus, intubated him, and have given three rounds of epi. They estimate a 15 minute down time prior to their arrival and a 10 minute transport time with no return of spontaneous circulation. In fact, things are going in the opposite direction as he has been in asystole for the past five minutes.
They move him onto the bed where your EMT takes over CPR. You note good and symmetric assisted breath sounds via the ET tube, but minimal palpable femoral pulse despite what appears to be good CPR to the tempo of the Bee Gees hit “Staying Alive”. On the monitor there is asystole in two leads. Pupils are fixed and dilated despite no atropine having been received. Things are not looking promising.
You request saline wide open and a final round of epinephrine while you take a look for cardiac motion with the ultrasound machine. To minimize interruption of CPR you don’t have the EMT pause until you are completely ready to look. You also have the RT hold respirations to avoid any artifact. There is no cardiac motion. You verbalize this to your team. The heart does not appear dilated and there is no pericardial effusion. You ask aloud, “anyone have any other suggestions” prior to calling the time of death.
Of course you next wonder what did him in: MI, PE, something else… His belly looks pretty protuberant, so you decide to take a quick look at his abdomen to check for free fluid. What you see is shown in the two images below. What do you think killed this gentleman?
What do the images show? Can you figure out why this man died? Conclusion on next page
Image 1 is a view of Morrison’s pouch in the right upper quadrant, but if you look closely you will notice that the structure that appears to be the kidney (labeled pseudokidney) has no renal pelvis. This is actually the liver, which has been displaced by a huge retroperitoneal hematoma (see Image 1a). The echotexture of the retroperitoneal hematoma is very similar to the liver.
Image 2 is a cross-sectional view of the abdomen from the epigastric area showing the liver, the massive retroperitoneal hematoma and the spine. The aorta and IVC are located anterior to the spine, but are difficult to identify as they are collapsed due to death from hemorrhagic shock.
Images 3 is similar to image 1 but the probe is rotated slightly more caudad to show the actual kidney. Image 4 is similar to image 2, but the probe is rotated more to the right to show more of the liver and to better show the actual size of the retroperitoneal hematoma, which is larger than the liver.
The patient’s family eventually arrived and confirmed that he had a known AAA, but had refused surgery.
Pearls & Pitfalls for Performing Code Blue & Post-Mortem Ultrasound
01 Start with the Heart: Look for cardiac motion, cardiac tamponade, or a dilated RV from a massive PE. If you see any of these there may still be a chance that the patient can be saved. Consider the patients underlying illnesses and code status, if known, as well as down time, age and whether or not there was bystander CPR as you decide what type of resuscitative efforts are appropriate. Management will depend on what you find. For a small rapidly beating heart give fluids. For tamponade, perform pericardiocentesis. For suspected PE, consider IV tPA.
02 Look at the Lungs: Assess for a tension pneumothorax or tension hydrothorax that might be contributing to the patient’s demise. Use ultrasound guidance to place a chest tube or during needle thoracostomy to prevent accidental puncture of adjacent structures.
03 Next, go to the Abdomen: Look for a AAA or intra-abdominal free fluid. As demonstrated in this case, a grossly ruptured AAA may be difficult to impossible to find; all you may see is a massive retroperitoneal hematoma. If that’s the case it is obviously too late. To save a patient with a AAA you need to make the diagnosis before they code, which is why it’s good to screen for the presence of AAAs in high risk patients. Get them to a vascular surgeon for follow up before they come back to your ED in full cardiopulmonary arrest.
04 Avoid Pitfalls: The best way to minimize errors is through experience, so scan lots of normal kidneys. With bedside ultrasound, there is no substitute for experience. The more scans you do, the better you will be able to differentiate abnormal from normal, even when you may not be sure exactly what the abnormality is. An image library of normal and abnormal ultrasounds helps immensely, so check out the Soundings archive on www.epmonthly.com.
Brady Pregerson (@TheSafetyDoc) manages a free online EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series. For more info visit EMresource.ORG.
Teresa S. Wu (@TeresaWuMD) is the Associate Residency Director, and Director of Ultrasound and Simulation Programs and Fellowships, for the Maricopa EM Program in Phoenix, Arizona.