Newly Published
Images in Anesthesiology  |   February 2019
Focused Cardiac Ultrasound during Amniotic Fluid Embolism
Author Notes
  • From the Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Correspondence: Address correspondence to Dr. Bronshteyn: Yuriy.bronshteyn@gmail.com
Article Information
Images in Anesthesiology / Cardiovascular Anesthesia / Obstetric Anesthesia / Radiological and Other Imaging / Respiratory System
Images in Anesthesiology   |   February 2019
Focused Cardiac Ultrasound during Amniotic Fluid Embolism
Anesthesiology Newly Published on February 11, 2019. doi:10.1097/ALN.0000000000002596
Anesthesiology Newly Published on February 11, 2019. doi:10.1097/ALN.0000000000002596
In emergency and critical care medicine, focused cardiac ultrasound is well-established to rapidly narrow the differential diagnosis of hemodynamic instability.1  Although anesthesiologists have traditionally relied upon transesophageal echocardiography for this indication, perioperative providers are recognizing the advantages of focused cardiac ultrasound for crisis management. Compared to transesophageal echocardiography, the equipment necessary to perform focused cardiac ultrasound is more portable, simpler to disinfect between examinations, less invasive, and increasingly ubiquitous in perioperative locations.
The focused cardiac ultrasound images (images A and B above; Supplemental Digital Content 1, http://links.lww.com/ALN/B854) show a subcostal four-chamber view in a previously healthy patient (A) who developed sudden cardiac arrest (B) at the conclusion of a cesarean section. The image was obtained in the transverse plane below the xyphoid process (Supplemental Digital Content 2, http://links.lww.com/ALN/B855). The finding of right ventricular to left ventricular area ratio greater than 1 in any four-chamber view identifies right ventricular dilation (Supplemental Digital Content 3, http://links.lww.com/ALN/B856). Right ventricular dilation implicates high right ventricular afterload. In otherwise healthy parturients, this narrows the differential diagnosis of shock primarily to amniotic fluid embolism and pulmonary embolism. Point-of-care ultrasound evaluation of the lower extremity veins may help distinguish between the two: finding a noncompressible lower extremity vein increases the probability of pulmonary embolism (Supplemental Digital Content 4, http://links.lww.com/ALN/B857).2  In contrast, concurrent disseminated intravascular coagulation argues for amniotic fluid embolism.