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The Speed of Sound

The Speed of Sound

Always #Echofirst to Make the Right Diagnosis

Butts, Christine MD

doi: 10.1097/01.EEM.0000719124.95453.28
    echo, heart, ultrasound
    echo, heart, ultrasound:
    A still image of a parasternal long axis view of the patient's heart. Watch two videos at http://bit.ly/SpeedofSoundVideos to judge the cardiac function for yourself.
    Figure
    Figure

    A 19-year-old man presented to the emergency department complaining of fatigue, nausea, and vomiting. He was evaluated for possible appendicitis, and his CT scan and COVID-19 test were negative. He received some fluids and antiemetics, and he felt better and was discharged.

    He returned to the ED two days later still unable to tolerate anything by mouth and was feeling even more fatigued. This time he was also febrile and tachycardic.

    Emergency medicine is a tricky business. We see thousands of cases where we have some time to gather data, synthesize, and make decisions. To be honest, a lot of times patients get better no matter what we do. Certainly, there are some cases in which we can make a quick diagnosis and really save a life. And then there are cases where we make the wrong initial decision and make things worse. This was one of those cases.

    When a previously healthy 19-year-old man presents with fatigue, nausea, and vomiting, our first thoughts are probably gastroenteritis. Or maybe some bad takeout. How many times have we seen this patient or one similar to him? Give him some fluids, some antiemetics, and he looks great after an hour.

    This patient received 2 L of fluids and acetaminophen for fever. A slew of labs were ordered, including a repeat COVID-19 test. A chest x-ray was added to search for a source of his illness. An hour later, the patient's nurse said his blood pressure was lower, systolic now in the 70s. His breathing was worsening, and he was now hypoxic. The lab called to say that his COVID-19 swab was positive. Given the low blood pressure, ultrasound was brought to the bedside to assess the IVC. Maybe he needed more fluids? Maybe it was a pulmonary embolus?

    The ultrasound showed a tachycardic heart that initially looked to be contracting well. (Video 1; see photo and caption.) Tachycardia can fool the eye into thinking the heart is contracting better than it is. When this video is slowed down, the truth comes out. (Video 2.) You can do this yourself on your machine by saving a clip and scrolling through it frame by frame. A normally contracting heart should show two things: The myocardium should thicken by 50 percent, and the chamber size should decrease by a third in systole. When you slow this video down, it's easy to see that his heart is barely contracting although it is beating rapidly. The volume ordered after the initial exam was only worsening this patient's heart failure.

    This patient's diagnosis? Myocarditis, most likely due to coronavirus infection, not the first thing we think of when we see a 19-year-old with nausea and vomiting. All the more reason to take a second to check his heart before pouring in fluids. Choosing #echofirst helps us do no harm to our patients and choose the right path from the start.

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    Dr. Buttsis the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her on Twitter@EMNSpeedofSound, and read her past columns athttp://bit.ly/EMN-SpeedofSound.

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