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Using POCUS for decision-making in CP R/O ACS cases

September 22, 2016 1 Comment

Can POCUS help you in the management of chest pain rule-out ACS cases? Let’s have a look at a case…

A few months ago, a man in his mid-60s presented with a chief complaint of chest pain. Past history included dyslipidemia and a remote lower extremity orthopedic injury. The patient smoked 3/4 ppd. He had no past history of cardiac disease or venous thromboembolism. That morning, he went out for a walk and developed some central chest pressure without radiation. He rested and the pain went away after a few minutes. The pain recurred that evening while he was doing some work in the yard. There were several stuttering episodes of chest pain, each of which would last a few minutes and would mostly go away. There were no associated symptoms aside from some diaphoresis. EMS was activated. The heart rate would vary from the mid-40s to the mid-60s range. The patient was mildly hypertensive with the systolic BP in the 170s range. And he appeared to be uncomfortable due to the chest pain. But the physical exam was otherwise negative. Here is the patient’s ECG.

STEMI ECG CROPPED

As you can see, it looks like there was early ST elevation and perhaps some hyperacute Ts in the anterior leads. But there were no reciprocal changes. There are multiple considerations in a patient like this. Of course, ACS is at the top of the list. But one needs to consider a large PE, aortic dissection, etc. Serial ECGs are useful in such patients to see if the ECG changes evolve. But that takes time. To try to hone in on the diagnosis as quickly as possible, a Cardiac POCUS scan was performed early in the patient’s course. The video below shows this patient’s parasternal long view. Before you scroll down below the video, decide for yourselves what you think. Is there an effusion? What about the LV? Is there any evidence of RV strain? And, although we don’t specifically mention this at EDE 2, do you think the aortic root is dilated?

There was no effusion. There were no findings consistent with RV strain. Also, the aortic root was not dilated (criteria: > 4 cm). What jumps off the screen? Motion of the lateral LV free wall seems fine, but the distal septum and apex just aren’t moving well at all. I know what you’re thinking. At EDE 2, we teach the parasternal long view and how to look for global LV systolic function. But we do not teach how to assess for regional wall motion abnormalities. However, when it’s this obvious, such findings can be used to guide management and narrow the DDx. In this case, it allowed the team to contact cardiology earlier with greater certainty that this patient had a STEMI, even though the ECG wasn’t that impressive. The patient was taken expeditiously to the cath lab where an LAD occlusion was opened and stented. The cardiologist came down afterwards to let the team know what happened and said that “we saved a life”.

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  1. Lloyd Gordon says:

    Excellent case (and video).

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