An evidence-based approach to emergency ultrasound.

Paramedics bring into the ED an elderly man who is complaining of right-sided chest and abdominal pain. Earlier this morning, a friend had arrived at the patient's home and found him on the floor at the bottom of the stairs. The patient is in pain, somewhat altered, and unable to provide further details about what happened. After numerous attempts, the paramedics were only able to place a 22-gauge peripheral line. On examination, his blood pressure is 98/55 mm Hg, heart rate is 118 beats per minute, respiratory rate is 32 breaths per minute, oxygen saturation is 94% on a nonrebreather, and temperature is 36.0 degrees C (96.8 degrees F). His Glasgow Coma Scale score is 12 (eyes 3, verbal 4, motor 5). Given the unclear events surrounding his presentation and the concern for trauma, the patient is boarded and collared. His chest is stable but tender, and because of noise in the resuscitation room, you have difficulty auscultating breath sounds. The abdominal examination is notable for marked tenderness over the right upper quadrant and right flank, with some guarding. There is also mild asymmetric swelling of his right lower extremity. The patient is critically ill, his history is limited, and at this point the differential is quite broad. You consider the possibility of a syncopal episode followed by a fall, with a closed head injury, blunt thoracic trauma, and blunt abdominal trauma. His hypotension could be secondary to hypovolemia (dehydration or blood loss due to a ruptured aortic aneurysm), heart failure (left- or right-sided dysfunction), cardiac tamponade, tension pneumothorax, or sepsis. Your ED recently purchased an ultrasound machine, you wonder whether bedside ultrasound can help narrow the differential and guide your resuscitation. You call over one of your new faculty members who just finished resident training; a fortunate decision for both you and the patient.