Doppler ultrasonography is a standard in diagnosis of deep vein thrombosis (DVT) but is often delayed. Clinician-performed focused vascular sonography (FVS) has proven to accurately diagnose DVT in the ambulatory and emergency room settings. Whether trained medical residents can perform quality FVS in the critically ill is unknown. Medical residents were trained in a 2-hour module in FVS assessing for complete compressibility of common femoral and popliteal veins. Residents imaged consecutive medical ICU and intermediate care patients awaiting comprehensive, sonographer-performed and radiologist-interpreted examinations. Sensitivity, specificity, positive and negative predictive values of the focused examination were calculated against the comprehensive study. Fleiss Kappa (κ), the degree of agreement between resident and radiologist, was calculated. Time savings was measured. Nineteen residents performed 143 studies on 75 patients. Twelve patients had above-the-knee DVTs, a prevalence of 16 %. All 6 common femoral and 7 of 9 popliteal vein DVTs were identified. None of 6 isolated superficial femoral DVTs were identified. Sensitivity for above-the-knee DVT was 63 %, specificity 97 %. Sensitivity for common femoral and popliteal DVT was 86 %, specificity 97 %. Residents showed substantial agreement with radiologists for diagnosis of DVT (κ = 0.70, SE 0.114, p < 0.001).Time from order of a formal ultrasound to a radiologist's read averaged 14.7 h. The two-point compression ultrasound method demonstrated insufficient sensitivity in a cohort of critically ill medical patients due to a high-incidence of superficial femoral DVT. However, residents demonstrated substantial agreement with radiologists for the diagnosis of clinically relevant DVT after a 2-hour course. FVS should include the superficial femoral vein and is associated with a significant time savings.
Purpose . Intensivist-performed focused echocardiography (FE) is accepted practice. Whether medical residents can perform and interpret quality FE in the critically ill is unknown. Methods . Novice residents trained in an 8-hour module in FE, evaluating ejection fraction (EF), pericardial effusion, right ventricular (RV) strain, valvular pathology, wall motion abnormalities (WMAs), and inferior vena cava collapsibility in patients awaiting comprehensive echocardiograms. The Fleiss kappa ( κ ), sensitivity, specifi city, positive predictive values, and negative predictive values were calculated against the comprehensive echocardiogram. Results . Seven residents performed 102 FE, demonstrating substantial agreement with cardiologists for EF as decreased versus normal or hyperdynamic ( κ = .67, P < .001, sensitivity = 94%, specifi city = 93%) and pericardial effusion ( κ = .60, P < .001, sensitivity = 85%, specifi city = 93%); moderate agreement for aortic stenosis ( κ = .54, P < .001, sensitivity = 56%, specifi city = 98%), aortic insuffi ciency ( κ = .50, P < .001, sensitivity = 47%, specifi city = 97%), mitral regurgitation ( κ = 0.51, P < .001, sensitivity = 65%, specifi city = 90%), and WMAs ( κ = .49, P < .001, sensitivity = 71%, specifi city = 88%) and fair agreement for RV strain ( κ = .38, P < .001, sensitivity = 41%, specifi city = 95%). Conclusions . After an 8-hour course, resident FE demonstrated substantial agreement with comprehensive echocardiography for EF and pericardial effusion, moderate agreement for valvulopathy and WMAs and fair agreement for RV strain. Sensitivity and specifi city were high for systolic dysfunction and pericardial effusion. Whereas sensitivity was lower for RV strain, valvular abnormalities, and WMAs, residents demonstrated excellent specifi city for all parameters studied. Clinical implications . FE can be taught to residents to hasten diagnosis of key pathologies while awaiting comprehensive echocardiography.
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INTRODUCTION:Type A aortic dissection is a surgical emergency that is often misdiagnosed but carries a mortality up to 50 percent at 30 days if treated with medical therapy alone. We present a case of aortic dissection with the uncommon presentation of acute cerebral ischemia, acute coronary syndrome (ACS), and coagulopathy. CASE PRESENTATION:A 71-year-old man with history of renal stones, vertigo, arthritis, and benign prostatic hyperplasia experienced chest pain with syncope while at home. En route to the hospital his systolic blood pressure was 220 mmHg and he developed nausea, vomiting, and left sided weakness with left facial droop. On arrival to the ED he was intubated for airway protection. Noncontrast computed tomography (CT) scan of the head did not show evidence of infarct or hemorrhage. He was being considered for systemic thrombolysis but excluded due to elevated international normalized ratio (INR) and CT brain perfusion analysis showing a large right middle cerebral artery (MCA) infarction with dissection of carotid arteries as well as suspected aortic dissection. CT angiography of the brain confirmed aortic arch dissection, narrowing of bilateral common carotid arteries due to the dissection flaps with occlusion of right internal carotid artery, right MCA and A1 segment of right anterior cerebral artery. Subsequent CT aortic angiography showed type A dissection of ascending aorta and hemorrhagic pericardial effusion. Labs were significant for a prothrombin time of 34s, INR of 3.5, partial thromboplastin time of 47.8s, platelets of 98 K/ mm3, and fibrinogen of 49 mg/dL. Troponin was elevated to 7.7 ng/ml. Cardiothoracic surgery was consulted but patient was deemed not to be a candidate for intervention due to large CVA and suspicion of DIC. In the ICU the patient developed progressive shock requiring vasopressors. Family decided against aggressive measures and a do not resuscitate order was placed. Patient died approximately 36 hours after arrival to the emergency. DISCUSSION:The triad of acute ischemic stroke, acute coronary syndrome, and coagulopathy is not a common presentation of aortic dissection but should prompt a high level of suspicion for the diagnosis with early surgical consultation and cautious use of thrombolytics, which are an absolute contraindication in aortic dissection. Medical management alone for type A dissection has high mortality. It includes blood pressure control with beta blockers, monitoring in the intensive care setting (ICU) and pain management.CONCLUSIONS: Patients with aortic dissection (type A) can have variable complications, the treatment of which are contradictory to each other. Unfortunately, such complicated cases are poor surgical candidates as well.
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