Case 4 - Bubbles, bubbles, bubbles...

Author: Nish Cherian Reviewer: Nick Mani

A 70-year old female is brought into Resus with altered mental status and SOB. She was found collapsed in the bedroom by her husband. SpO2 90% on 15L O2, tachycardic, BP 100/60, T 38.4.

There is a long delay in x-ray. POCUS is performed and shows the following:

Clip 1. PLAX

Clip 2. IVC

Clip 3. Right lung base

Clip 4. Right lung base (R3/4), more proximal

• Describe the LV function

  Moderate-severe LV systolic impairment

• What does the IVC show?

  Dilated IVC with <50% inspiratory variation (correlates with CVP of approx 11-15mmHg)

• What sign is shown in Clip 3 and what pathology is indicated?

  “Spine sign” - extension of the vertebral bodies proximal to the diaphragm. This would indicate the presence of a good conductor of sound above the diaphragm (i.e. loss of the normal air interface). In this case, it is due to fluid (anechoic).

• What pathology is shown in Clip 4?

  Lobar consolidation with static air bronchograms and parapneumonic effusion (note the debris above the diaphragm)

Case resolution

POCUS helped to clinch the diagnosis and expedite care. Vasopressors were commenced early in this patient given her poor LV function and risk of fluid overload. She was intubated for hypoxic respiratory failure and transferred to the ICU and treated for a community acquired pneumonia. CXR was eventually performed (see below).

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Appendix

Image 1. CXR