A 32 year old doctor playing recreational soccer got more than he bargained for…
… when he sustained a femoral fracture during a tackle by his over-competitive buddies. Previously well, he was admitted to the ICU due to tachypnoea and hypoxia (89% on 8L O2 via Hudson mask), but with a normal CXR. The following images were obtained…
Lung sliding with A lines is present. Diagnostic entities in this section of the BLUE protocol include asthma, PE, and pneumonia; pneumothorax is excluded.
Global left ventricular function is normal.
Mild pulmonary valve regurgitation – a common finding.
Yes – there is subtle diastolic flattening of the septum, which can occur in the context of right ventricular volume overload.
The tricuspid valve, with mild tricuspid regurgitation.
Assuming right atrial pressure is 15mmHg (based on IVC measurements), the estimated right ventricular systolic pressure is severely elevated at 76.5 mmHg.
There is systolic notching in the RVOT VTI trace, consistent with elevated pulmonary vascular resistance.
Differentials for this presentation with hypoxia would include DVT with PE, and fat embolism. In this case later evolution of subtle airspace opacity and petechiae suggested fat embolism as the cause in the context of the long bone fracture. The patient never developed the third component of the triad, neurological impairment, and made a good recovery.
Cover image: © BrokenSphere / Wikimedia Commons
