A 47-year-old man was brought to the ED with acute delirium and severe dyspnea. He was unwell for the past several days with a low-grade fever, dry cough, exertional dyspnea, and fatigue. His medical history included hypertension, diabetes mellitus, and end-stage renal disease requiring hemodialysis through a fistula in his left arm.
On presentation, the patient had a BP of 80/40 mm Hg, a regular heart rate at 120/min, a temperature of 38°C, and a respiratory rate of 32/min. His oxygen saturation was 84% on an Fio2 of 1.0. The physical examination revealed an obtunded male with bilateral vesicular breath sounds without crackles or rhonchi. Cardiac auscultation revealed normal first and second heart sounds and a grade 1/6 systolic murmur over the apical area. Skin examination showed several palpable purpuric spots on the lower extremities and a gangrenous fourth toe tip on the left foot. Chest radiograph showed bilateral alveolar opacities. CT scan of the brain was normal. Pertinent laboratory values were hemoglobin,7.5 g/dL; WBC, 3,600/μL; creatinine, 5.4 mg/dL; and an arterial blood gas of pH 7.30, Paco2 of 25 mm Hg, Pao2 of 48 mm Hg, and bicarbonate of 12 mEq/L. Lactate level was 8 mEq/L. The patient was placed on mechanical ventilation, and volume resuscitation was started for a presumptive diagnosis of pneumonia with septic shock. The patient was admitted to the medical ICU where the critical care team immediately performed bedside ultrasonography to assess the cause of his hypotension and hypoxemic respiratory failure (Videos 1-6).