Ultrasound Case #14 – You’re pain in my… hip
A 72 year old female with previous history of COPD and osteoporosis presents via EMS to the EC with complaints of severe left hip pain after sustaining a witnessed fall outside of home. She tells you she was trying to get the newspaper when she slipped on her icy porch and fell onto her left side. She denies any head trauma or loss of consciousness and is not on any oral anticoagulation at home. She just complains of severe hip pain. She is vitally stable, fully alert and oriented. On physical examination her left lower extremity appears deformed, externally rotated, and shorter when compared to the right. When addressing pain control with her, she reports that opioid medications “have never agreed with me” and have caused issues with breathing in the past.
What can you offer this patient for more direct, longer-acting pain control in this setting?
Based on the pre and post cardiac ultrasound images below, do you think the patient benefitted from a fluid bolus?
Click to reveal answer
Image #1 –
You’ll place the probe in the left lateral position to obtain a 5-chamber apical view. This is so you can see the outflow tract. Press pulse wave on the machine, and that will bring up this indicator (white line through the picture) on the screen. Place the gate (two horizontal lines on the indicator) just proximal to the aortic valves; try to get the doppler line as close to 0 degrees as possible from the LVOT for the most accurate measure. Select VTI and you’ll get this tracing at the bottom of the picture. Highlight the outline of the large negative wave. The measurement for VTI will show up on the screen. This patient’s VTI is = 17.09; this is less than the goal of > 18.
Image #2 –
You will redo this test again after giving a 500 mL bolus or a passive leg raise. After we gave a 500 mL bolus of normal saline and measured the patient’s VTI. Her new VTI = 23.27. The goal for this second VTI is an increase of > 15%. This patient’s VTI increased by 36% showing a successful fluid bolus test.
Image # 3 & 4 –
These images are the patient’s internal jugular vein (IJV) collapsibility index. This is an indicator of the patient’s preload which is important in making a clinical decision in whether or not the patient will respond well to fluids or if they are at risk for being fluid overloaded.
With a linear probe and with M mode on the machine you will record a tracing of the IJV while applying pressure and not applying pressure in the same tracing. A collapsibility of < 39% is an indicator that the patient is not dehydrated (the veins are full of blood and therefore more difficult to compress). An IJV collapsibility index > 39% suggests that the patient has some level of dehydration (the veins are not full of blood and you can compress the vein more).
In image #3 the collapsibility is = 65% indicating that she is dehydrated and she would benefit from fluids. This was taken before giving the patient her initial 500 mL bolus.
Unfortunately, image #4 was not uploaded completely to our database and the measurements were not transferred over. This image was post 500 mL bolus. It appears that the patients IJV collapsibility index was still > 39% and she would benefit from more fluids.
It is important to remember to use the patient’s history and clinical presentation with an LVOT VTI and IJV-CI in order to make an informed decision about fluid resuscitation and to not just use information from only one of these components. Get the whole story!
Click to reveal learning points
- Because cardiac output is dependent on stroke volume, heart rate and contractility, it is important to look at both IJ collapsibility and left ventricular outflow tract velocity time integral (LVOT VTI) as a surrogate for whether or not a patient may benefit from fluid administration
- Normal left ventricular outflow tract velocity time integral (LVOT VTI) is >18
- Normal IJV collapsibility is <39%
- >15% change in LVOT VTI indicates appropriate response to a fluid challenge