Injury_at_Galaxy_at_Earthquakes_2010-08-21_2 © BrokenSphere / Wikimedia Commons

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…

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Findings were similar on the left and right side. How would you interpret this lung ultrasound image?

Lung sliding with A lines is present. Diagnostic entities in this section of the BLUE protocol include asthma, PE, and pneumonia; pneumothorax is excluded.

 

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What is the left ventricular function?

Global left ventricular function is normal.

 

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What is the significance of this finding?

Mild pulmonary valve regurgitation – a common finding.

 

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Any features of an overloaded RV?

Yes – there is subtle diastolic flattening of the septum, which can occur in the context of right ventricular volume overload.


 

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Which valve is this, what is the abnormality and how severe is it?

The tricuspid valve, with mild tricuspid regurgitation.

 

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Can you calculate the pulmonary pressures?

Assuming right atrial pressure is 15mmHg (based on IVC measurements), the estimated right ventricular systolic pressure is severely elevated at 76.5 mmHg.

 

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Are there any additional supportive features in this trace for elevated PVR?

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

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