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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.