Emergency Ultrasound of the Aorta Fahad Khan, MD St. Luke’s/Roosevelt Hospital Center Columbia University, New York City April 24, 2009.

Emergency Emergency Ultrasound of the Ultrasound of the

AortaAortaFahad Khan, MDFahad Khan, MD

St. Luke’s/Roosevelt Hospital CenterSt. Luke’s/Roosevelt Hospital CenterColumbia University, New York CityColumbia University, New York City

April 24, 2009April 24, 2009

CaseCase

70 y/o male presents after 70 y/o male presents after witnessed syncopal episodewitnessed syncopal episode

Upon awakening, patient Upon awakening, patient complained of feeling weakcomplained of feeling weak

Patient walked to bathroom and Patient walked to bathroom and collapsedcollapsed

CaseCase

Afebrile, 110, 95/50, 18, 98% RAAfebrile, 110, 95/50, 18, 98% RA Appears pale, diaphoreticAppears pale, diaphoretic Tachycardic, S1S2Tachycardic, S1S2 CTABCTAB Abd: soft, periumbilical tenderness, no Abd: soft, periumbilical tenderness, no

rebound, no guardingrebound, no guarding Otherwise unremarkable examOtherwise unremarkable exam

Abdominal UltrasoundAbdominal Ultrasound

Risk Factors for AAARisk Factors for AAA

MaleMale AtherosclerosisAtherosclerosis SmokingSmoking HypertensionHypertension AgeAge

Key QuestionKey Question

Is there an abdominal aortic aneurysm?Is there an abdominal aortic aneurysm? Aorta >3cmAorta >3cm Iliac >1.5cm Iliac >1.5cm

IndicationsIndications

Suspected AAASuspected AAA Pulsatile abdominal massPulsatile abdominal mass Unexplained hypotension/ CV Unexplained hypotension/ CV

collapsecollapse ElderlyElderly

Unexplained back/flank painUnexplained back/flank pain Unexplained hematuriaUnexplained hematuria

Abdominal Aorta Abdominal Aorta AnatomyAnatomy

Minimal CriteriaMinimal Criteria

TransverseTransverse 1) Proximal aorta1) Proximal aorta 2) Mid aorta2) Mid aorta 3) Distal aorta3) Distal aorta 4) Iliac bifurcation4) Iliac bifurcation

SagittalSagittal 5) Infra-renal5) Infra-renal

TechniqueTechnique

Low Frequency 2-5 MHz

Transverse ViewsTransverse Views

Proximal Aorta Proximal Aorta TransverseTransverse

Splenic Vein Superior Mesenteric Artery

Aorta

Proximal AneurysmProximal Aneurysm

Mid Aorta TransverseMid Aorta Transverse

AortaIVC

Spine

Aortic AneurysmAortic Aneurysm

Sagittal AortaSagittal Aorta

Head Feet

Longitudinal AneurysmLongitudinal Aneurysm

Distal Aorta and Distal Aorta and Bifurcation TransverseBifurcation Transverse

Aortic Bifurcation TransverseAortic Bifurcation Transverse

Right Common Iliac Artery

Left Common Iliac Artery

Spine

Distal AneurysmDistal Aneurysm

PitfallsPitfalls

Only true contraindication – delaying Only true contraindication – delaying immediate surgical interventionimmediate surgical intervention

Over-reliance – finding a AAA, does Over-reliance – finding a AAA, does not mean it has rupturednot mean it has ruptured

Error in imaging – parasagittal planeError in imaging – parasagittal plane Patient factors – body habitus, bowel Patient factors – body habitus, bowel

gasgas

Useful clinical information can be Useful clinical information can be obtained from emergency ultrasound of obtained from emergency ultrasound of the abdominal aorta quickly, and with the abdominal aorta quickly, and with accuracy as compared to CT.accuracy as compared to CT.

Emergency ultrasound of the abdominal aorta Emergency ultrasound of the abdominal aorta is very sensitive and specificis very sensitive and specific

Can guide and expedite urgent vascular Can guide and expedite urgent vascular consultation consultation

AAA can be effectively excluded by bedside AAA can be effectively excluded by bedside emergency ultrasound regardless of patient’s emergency ultrasound regardless of patient’s dispositiondisposition

Questions?Questions?