85yo tachy Brady explained

So this is an elderly patient with no past medical history and no meds who presents with syncope in the context of alternating bradycardia, SVT and AF. The ECG shows non specific ST changes. 

It would have been easy to refer him to cardiology for a pacemaker. 

However, the registrar performed a RUSH exam due to the Hx of CP and back pain. 

(For more details on the RUSH exam, click on the button below: 

The echo shows a grade 2 mildly dilated LV consistent with the patient's age. The IVC is small and collapses >50%. In this patient, this could be due to peripheral vasodilation eg sepsis or intravascular fluid depletion eg diarrhoea and vomitting.

The FAST exam is interesting: there is minimal intraperitoneal fluid, but there is haematoma around the L kidney which is indicative of retroperitoneal pathology

Retroperitoneal haematoma may be due to a renal laceration (usually due to trauma), ruptured AAA or due to bleeding disorders.

In this elderly patient with chest and back pain, it would be prudent to check his aorta for a AAA/ dissection.

Just putting the abdominal probe on the epigastrium revealed a trans view of a dilated aorta

 Bedside US showing a AAA with evidence of rupture as in this case, is an indication for theatre without CT (1,2)

REFRENCES

1. Diaz O, Eilbert W. Ruptured abdominal aortic aneurysm identified on point-of-care ultrasound in the emergency department. Int J Emerg Med. 2020 May 14;13(1):25. doi: 10.1186/s12245-020-00279-9. PMID: 32410576; PMCID: PMC7227275.

2. Schmitz-Rixen T, Böckler D, Vogl TJ, Grundmann RT. Endovascular and Open Repair of Abdominal Aortic Aneurysm. Dtsch Arztebl Int. 2020 Oct 20;117(48):813-819. doi: 10.3238/arztebl.2020.0813. PMID: 33568258; PMCID: PMC8005839.