It is 4 o'clock in the morning. You are working an overnight shift in a busy emergency department when EMS calls in a stroke activation. They report the patient awoke moments earlier with extremity weakness.
They arrive several minutes later with a 69-year-old woman with a blood pressure of 147/62 mm Hg, a respiratory rate of 30 bpm, a heart rate of 47 bpm, an Sp02 of 100%, and afebrile. The neurology service is at the bedside when the patient arrives. She has a history of hypertension and breast cancer, and is six months status-post total left breast resection. EMS explains that on their arrival, the patient was being carried by her husband after a vagal episode and had a systolic pressure of 60 mm Hg, which improved en route with a normal saline bolus.
The patient is placed in a critical care bed in your emergency department. She has normal mentation, and states that she awoke feeling generally weak and needing to have a bowel movement. Too weak to move, her husband carried her to the restroom and back to the bed, and he then activated EMS. The EMTs found the patient was not generally weak, but had left arm and right leg weakness. She was unable to walk and had a syncopal episode when they tried to move her to the stretcher.
The patient is in no obvious distress in the ED. Her neurologic exam reveals total paresis, severe sensory loss, and absence of deep tendon reflexes of the left upper and right lower extremities. Her right upper and left lower extremities exhibit normal motor function, sensation, and reflexes. She has a normal cranial nerve exam, and auscultation of her heart reveals bradycardia and normal heart tones. She has unremarkable pulmonary and abdominal examinations. Within 10 minutes of her arrival to the ED and prior to the completion of your exam, she is taken to radiology for a noncontrast CT scan of the brain, which shows no acute abnormality. When she returns to the ED, a portable chest x-ray is performed.
You continue your physical examination, and find that her left arm is cool and pulseless, as is her right leg. The nurse repeats her vital signs, and finds her blood pressure to be 60/28 mm Hg in the right arm with a heart rate of 45 bpm. A blood pressure reading is not taken in her left arm because of her mastectomy, but readings are obtained in her lower extremities: 132/62 mm Hg in the left lower extremity and 66/33 mm Hg in the right. A review of the chest x-ray shows an abnormally widened mediastinum. (Image 1.) The ultrasound machine is brought to the bedside, and an intimal flap is seen extending throughout the abdominal aorta. (Image 2.)Radiology is called back, and an emergent CTA of the thorax is ordered. CT surgery is consulted, and asked to come to the ED immediately.
This case not only demonstrates the capability of bedside ultrasound to aid in decision-making, but also highlights the complex nature of the pathology that emergency physicians encounter during their day-to-day routines. Next month, we will discuss the many learning points revealed in this case.
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