Emergency department right atrial pressure and intravascular volume estimation using right ventricular tissue Doppler bedside ultrasonography
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A 41 year old woman with a history of colon cancer metastatic to her lung and liver, presented to the emergency department severely dehydrated. Bedside ultrasonography revealed a tumor mass in her proximal inferior vena cava at the junction of the right atrium obstructing the ability to assess her volume status with inferior vena cava inspiratory collapse. Bedside emergency department cardiac tissue Doppler ultrasonography of the lateral right ventricle and pulse Doppler ultrasonography of the tricuspid valve was used to estimate her right atrial pressure and intravascular volume status.
KeywordsUltrasound Tissue Doppler imaging Right atrial pressure estimation Volume depletion Metastatic colon cancer
A 41-year-old woman with a past medical history of colon cancer metastatic to her lung and liver and a history of multiple rounds of failed chemotherapy, presented to the emergency department from home with a 2-week history of nausea and vomiting and decreased appetite and oral intake, weakness, mild shortness of breath on exertion and chronic abdominal pain. Her ED vital signs were temperature 98.7, heart rate 124, blood pressure 96/50, respiratory rate 22, room air oxygen saturation 100%, and her ECG showed sinus tachycardia. Her physical examination revealed an alert woman with a tachycardic heart rate, she had dry oral mucosa, her lungs were clear, she had moderate right side abdominal tenderness on palpation, and her legs had no edema and there was no popliteal tenderness. A portable chest X-ray revealed a normal heart size, no effusions and multiple lung nodules. Laboratory studies included a BUN of 14 mg/dl (normal 7–20 mg/dl) and creatinine 0.6 mg/dl (normal 0.5–0.9 mg/dl) and a BUN/creatinine ratio of 23.
The patient was given 2 l of intravenous normal saline in the emergency department and her vital signs normalized with a repeat blood pressure of 116/72 and heart rate of 80. Her lungs remained clear after rehydration. She was admitted to the oncology service for continued hydration and palliation therapy.
Our clinically dehydrated patient had a tricuspid pulse Doppler E wave diastolic velocity of 38.2 cm/s and a RV lateral wall tissue Doppler Ea wave diastolic velocity of 14.6 cm/s, and a E/Ea (38.2/14.6) ratio of 2.6, <6 and consistent with a right atrial pressure less than 10 mmHg and an intravascular volume depleted patient. The figures and supplemental video clips illustrate how bedside cardiac tissue Doppler ultrasonography can assist the emergency and critical care physician in the estimation of right atrial pressure and volume status especially in a patient with a proximal IVC that is difficult to visualize.
Bedside cardiac tissue Doppler ultrasonography of the lateral right ventricle and pulse Doppler ultrasonography of the tricuspid valve can assist the emergency and critical care physician in the estimation of right atrial pressure and intravascular volume status.
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- 1.Lang RM, Bierig M, Devereux RB et al (2005) Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18:1440–1463PubMedCrossRefGoogle Scholar