October 2013 Case of the Month

A 45yo male presented to the ED with c/o chest pain.  He stated that he had been on a 5 hour bus ride a few days prior, developed sudden onset shortness of breath, chest pain.  He arrived hypoxic to 86%, improved to 96% with supplemental O2.  His initial blood pressure was 100/60, tachycardic to 120.    He was placed on a monitor, labs were drawn and a bedside cardiac ultrasound was performed, revealing the following images:

)

)

ad1

In the Apical 4 chamber view, the Right Atrium cannot be visualized secondary to the large aortic aneurysm. Of note, a dissection can also be seen. This is much more visible in the parasternal long axis.

Normal measurement for the aortic root (obtained in parasternal long axis) is 4cm, measured from leading edge to leading edge (or outer wall to inner wall). As can be seen in the still image, the aortic root is measuring nearly 8cm.

This particular case is an excellent example of the positive impact ultrasound can have, when coupled with the clinical scenario. His history and presentation initially suggested an alternative diagnosis of pulmonary embolism, another potentially deadly diagnosis. The patient was expeditiously evaluated by cardiothoracic surgery and went to the OR, with successful repair.