A Shocking Finding
Department of Internal Medicine, Division of Pulmonary Medicine,
University of Utah
A 31-year-old male was admitted with altered mental status and Loperamide overdose.
A transthoracic echocardiogram was performed
Question
What is the finding?
- Severe hypovolemia
- Ventricular tachycardia
- Accelerated play-back speed
- Restrictive physiology
B. This is an apical 4-chamber view, demonstrating a oscillating ventricle. There is partial acoustic shadowing on the right side of the screen from lung shadow. While the sonographer was recording images, he witnessed a sudden change from sinus rhythm to ventricular tachycardia, later attributed to loperamide toxicity. In this case, cardiac arrest occurred during the echo exam and the etiology was apparent on telemetry. The examination was stopped, and CPR was initiated. Echocardiography can diagnose causes of a PEA/asystolic arrest, such as hypovolemia, tamponade, PE, or myocardial insufficiency. The FEEL exam has been described as a protocol for echo during CPR1,2. It is essential that the echo exam not interrupt CPR. A subcostal four chamber view is obtained during pulse check and should last less than 10 seconds. An experienced sonographer can acquire images in far shorter time. The entire duration of the exam should be recorded and analyzed when CPR has resumed. Electromechanical association can be assessed, and if present may predict increased survival.3
References
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Breitkreutz R, Price S, Steiger HV, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. Nov 2010;81(11):1527-1533.
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Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm. Critical care medicine. May 2007;35(5 Suppl):S150-161.
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Flato UA, Paiva EF, Carballo MT, Buehler AM, Marco R, Timerman A. Echocardiography for prognostication during the resuscitation of intensive care unit patients with non-shockable rhythm cardiac arrest. Resuscitation. Jul 2015;92:1-6.
