Case #7, Answer

 

Case Recap: Old lady with hypotension, tachycardia and JVD…

I think we all agree that this person is sick. Prior to pondering the wide differential do the Basics: 2 Large Bore IVs, O2 NC vs NRB, Monitor, assess airway

 

My Top Three Differential Diagnoses

1. Cardiac Tamponade

2. Massive PE

3. Inferior Wall MI with Cardiogenic Shock

 

Do you want to give fluids?

Tricky question! IV fluids helps BP in PE and Tamponade…but can be a poor idea in cardiogenic shock. Remember, in cardiogenic shock the heart can’t pump the fluid out leading to decreased venous return as demonstrated by JVD. Fluids in cardiogenic shock are generally a bad idea as they increase an already overloaded pre-load. Since her lungs are clear iIn this case, you can give a “100ml to 250ml bolus” [1] and reassess the patient for improved BP and the development of rales.

Once Basics Are Done

ECG and Echo. Yes, labs/cxr are also needed, but they won’t help you differentiate between the above three in a timely fashion.

Her Echo may have looked like this…

Apical 4

 

Parasternal Short

 

Parasternal Long

 

What findings are on these US images?

 

If the patient improves enough to get a CT...

 

Treatment?

 

By Dr. Andrew Grock

 

Special thanks to Dr. Ian deSouza.

 

References
[1] Tintinalli’s 7th ed.

[2]Stavros V. Konstantinides et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). European Heart Journal (2014) 35, 3033–3080 doi:10.1093/eurheartj/ehu283