Application of “Point-Of-Care-Ultrasound” (POCUS) in an Acute-Geriatrics-Unit: Case report

Aponte, Myriam Teresa; González-Montalvo, Juan Ignacio; Murillo Gayo, Concepción; Reinoso Párraga, Paola Pastora

doi:10.1016/j.regg.2024.101516

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(B) Abdominal computed tomography, with evidence of left iliopsoas hematoma measuring approximately 3.5cm×6cm×11cm without active bleeding." ] ] ] "textoCompleto" => "BackgroundPoint-Of-Care Ultrasound (POCUS) is a portable and accessible diagnostic technique that provides timely information at the bedside through multiple systems, in real time. Over the last decade there has been a significant increase in the adoption of POCUS and it is considered highly beneficial alongside traditional examination techniques in evaluating geriatric patients with acute illnesses.<a class="elsevierStyleCrossRefs" href="#bib0085">1,2</a>Several studies have demonstrated the usefulness of this tool in multiple medical specialties, since it allows not only to diagnose and treat, but also to monitor the response to treatments administered.<a class="elsevierStyleCrossRef" href="#bib0095">3</a>The objective of this case is to describe the utility of POCUS in the diagnosis of an 81-year-old elderly patient, hospitalized in an Acute-Geriatrics-Unit, who presented with hypotension and abdominal pain, and underwent POCUS, leading to the diagnosis of a left iliopsoas muscle hematoma.CaseWe present the case of an 81-year-old patient with past medical history of arterial hypertension, atrial fibrillation, type 2 diabetes mellitus, chronic liver disease, pulmonary hypertension, heart failure, sleep apnea hypopnea syndrome, depressive syndrome, mechanical aortic valve prosthesis anticoagulated with acenocumarol, right hemithyroidectomy, right radical nephrectomy due to renal mass, hysterectomy and recent admission due to a fall with head trauma, acute subdural hematoma and right humerus fracture.A comprehensive geriatric assessment was performed upon admission with the following results: Functional-Ambulation-Category (FAC) 3/5, Barthel-index 70/100 and the Global-Deterioration-Scale (GDS) 1/7.She was admitted to the Geriatric-Acute-Care Unit after an accidental fall with traumatic brain injury and chronic left hemispheric subdural hematoma with signs of acute rebleeding.On admission she was being treated with a dose of enoxaparin 40mg, hydroferol, sertraline, insulin, calcium, iron, furosemide, paracetamol, denosumab, allopurinol, tramadol, bisoprolol, digoxin and spironolactone.During hospitalization, she experienced an episode of hypotension and abdominal pain. The physical examination revealed abdominal distension and discomfort in the palpation in the mesogastrium and hypogastrium. Blood test showed anemia with hemoglobin level of 7.7g/dL with a previous level of 10g/dL. In light of these findings, POCUS was performed, revealing signs of hypovolemia with free fluid perihepatic and in the pelvis, and the presence of an anechoic image measuring 8.8cm×3.50cm×6.98cm in the left iliac fossa highly suggestive of muscular hematoma at that level (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Afterwards, the presence of a left iliopsoas hematoma measuring approximately 3.5cm×6cm×11cm without active bleeding was confirmed trough abdominal tomography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Conservative medical treatment was prescribed, including a transfusion of two units of packed red blood cells, along with analgesic therapy, leading to favorable clinical evolution.DiscussionSpontaneous, non-traumatic hematoma of the iliopsoas muscle mainly occurs in older adults undergoing anticoagulant treatment or with coagulation disorders. Clinical presentation is usually varied, including abdominal pain, hip or back pain and sometimes with neurological deficit in the lower limbs.<a class="elsevierStyleCrossRef" href="#bib0100">4</a> Symptoms are often atypical and Lenk's triad (flank pain, hemodynamic shock and palpable mass) occurs in very few cases.<a class="elsevierStyleCrossRef" href="#bib0105">5</a>It can be a critical condition and sometimes lead to serious complications, particularly in elderly patients and patients with comorbidities, so suspicion and rapid identification are crucial for appropriate treatment.The incidence of spontaneous iliopsoas hematoma ranges from 0.3 to 0.4% in patients hospitalized in intensive care units, with and estimated mortality rate ranging from 30 to 50%.<a class="elsevierStyleCrossRef" href="#bib0105">5</a>Diagnosis is usually made by through standardized imaging tests such as computed tomography, highlighting the importance of implementing POCUS in Acute-Geriatric-Units due to its easy and quick access for diagnosing this condition and enabling early intervention.Cases of early diagnosis using POCUS have been described in the literature for conditions such as muscle and soft tissue hematomas, abdominal pathologies like acute cholecystitis, hypovolemia and hypervolemia, pleural effusion, interstitial lung disease, cellulitis, and deep vein thrombosis, as well as its utility in upper airway management and biceps tendon injury diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0110">6–8</a>Various studies have shown evidence that supports the use of POCUS as a complement to traditional management techniques in older patients, favoring diagnostic accuracy, establishing the diagnosis in the shortest possible time and being able to initiate the appropriate treatment, which translates into better outcomes for the patient.<a class="elsevierStyleCrossRef" href="#bib0090">2</a>Conflict of interestThe authors declare not to have any interest conflict." "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 666 "Ancho" => 1476 "Tamanyo" => 103426 ] ] "descripcion" => array:1 [ "en" => "(A) Point-Of-Care Ultrasound (POCUS) with presence of left iliopsoas hematoma. 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