Emergency department right atrial pressure and intravascular volume estimation using right ventricular tissue Doppler be
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CASE REPORT
Emergency department right atrial pressure and intravascular volume estimation using right ventricular tissue Doppler bedside ultrasonography David C. Riley • Samuel Gerson • John Arbo
Received: 11 March 2010 / Accepted: 13 April 2010 / Published online: 12 May 2010 Ó Springer-Verlag 2010
Abstract A 41 year old woman with a history of colon cancer metastatic to her lung and liver, presented to the emergency department severely dehydrated. Bedside ultrasonography revealed a tumor mass in her proximal inferior vena cava at the junction of the right atrium obstructing the ability to assess her volume status with inferior vena cava inspiratory collapse. Bedside emergency department cardiac tissue Doppler ultrasonography of the lateral right ventricle and pulse Doppler ultrasonography of the tricuspid valve was used to estimate her right atrial pressure and intravascular volume status. Keywords Ultrasound Tissue Doppler imaging Right atrial pressure estimation Volume depletion Metastatic colon cancer
Case report A 41-year-old woman with a past medical history of colon cancer metastatic to her lung and liver and a history of multiple rounds of failed chemotherapy, presented to the emergency department from home with a 2-week history of nausea and vomiting and decreased appetite and oral intake, weakness, mild shortness of breath on exertion and
Electronic supplementary material The online version of this article (doi:10.1007/s13089-010-0030-7) contains supplementary material, which is available to authorized users. D. C. Riley (&) S. Gerson J. Arbo Emergency Medicine Department, Columbia University Medical Center, 622 West 168th Street, PH 1-137, New York, NY 10032, USA e-mail: [email protected]
chronic abdominal pain. Her ED vital signs were temperature 98.7, heart rate 124, blood pressure 96/50, respiratory rate 22, room air oxygen saturation 100%, and her ECG showed sinus tachycardia. Her physical examination revealed an alert woman with a tachycardic heart rate, she had dry oral mucosa, her lungs were clear, she had moderate right side abdominal tenderness on palpation, and her legs had no edema and there was no popliteal tenderness. A portable chest X-ray revealed a normal heart size, no effusions and multiple lung nodules. Laboratory studies included a BUN of 14 mg/dl (normal 7–20 mg/dl) and creatinine 0.6 mg/dl (normal 0.5–0.9 mg/dl) and a BUN/ creatinine ratio of 23. An ED bedside ultrasound was performed of the abdomen and heart (see Video Clips S1, S2, S3 and S4 available as supporting information in the online version of this paper) and revealed an enlarged liver with diffuse metastatic tumor masses (Fig. 1) and a hyperdynamic heart (Video Clip S2). The inferior vena cava was collapsed in the subcostal short axis view (Fig. 2). The inferior vena cava contained a tumor mass at the junction of the right atrium in the subcostal long axis view (Fig. 3). In addition, in the apical four chamber view, pulsed wave Doppler evaluation of the tricuspid valve (at the coaptation point of the tr
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