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A 44-Year-Old Woman Presents to the ED With Agitation, Dyspnea, and Hypotension FREE TO VIEW

Francesco Mojoli, MD; Anita Orlando, MD; Silvia Mongodi, MD; Antonio Braschi, MD
Author and Funding Information

CORRESPONDENCE TO: Francesco Mojoli, MD, Fondazione IRCCS Policlinico San Matteo, Anesthesia and Intensive Care 1st, Viale Golgi, 19, 27100 Pavia, Italy


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(5):e137-e139. doi:10.1016/j.chest.2015.11.033
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Published online

October 9, 2013

3:00 pm

The rescue team is called for respiratory distress in a 44-year-old woman, who is found agitated and tachycardic, with BP 100/65 mm Hg. She is brought to the ED with the diagnosis of panic attack.

In the ED she becomes more hypotensive (BP, 90/60 mm Hg), so she is shifted to an acute-care bed and given intravenous fluids. Arterial blood gas analysis shows compensated lactic acidosis and hypoxemia (pH 7.38; lactates, 7 mM; Paco2, 27 mm Hg; Pao2, 60 mm Hg). Further history reveals chronic anemia and hemorrhoids; digital rectal exploration shows purulent fluid. A surgical consultation is requested (it having been determined that there was no need for urgent surgery).

4:00 pm

After fluid resuscitation, she becomes more hemodynamically stable (BP, 125/75 mm Hg), although still tachypneic, tachycardic, and hypoxemic (Pao2, 64 mm Hg; oxygen saturation as determined by pulse oximetry, 94%; fraction of inspired oxygen, 50%). A basal CT scan (Video 1) shows a perianal abscess, hepatomegaly, and bilateral pulmonary consolidations, described as probably inflammatory.

5:00 pm

On return from the CT unit the patient is still tachypneic, again hypotensive (BP, 90/60 mm Hg), and anuric since admission. A central venous access is inserted and norepinephrine started. The intensive care team is called.

5:30 pm

The patient is admitted to the general ICU with the diagnosis of septic shock from perianal abscess; hyperlactacidemia progressively worsens (11.2 mM). Blood cultures are taken and empiric broad-spectrum antibiotics are started.

8:00 pm

The patient is intubated for exhaustion. On the basis of the unfolding clinical history, the physical examination, and another look at the CT scan, which raises a doubt about enlargement of the right side of the heart, the ICU team performs a goal-directed ultrasound (Video 2, ultrasound examination).

Question: Based on the ultrasound videos in conjunction with the clinical story, what is the most likely diagnosis for the patient’s shock state?

Answer: To verify the hypothesis of acute pulmonary embolism a focused cardiac ultrasound is done and acute cor pulmonale is clearly diagnosed. Point-of-care ultrasound examination is completed by vascular ultrasound, showing a thrombus in the left superficial femoral vein, and lung ultrasound, showing focal B-lines and subpleural consolidations.

The focused echo examination shows all the typical features of acute cor pulmonale (enlarged right ventricle, compressed left ventricle with paradoxical septum, dilated and fixed inferior vena cava), providing a satisfactory explanation for the clinical findings. Point-of-care ultrasound examination is then extended to the lungs (showing focal B-lines and subpleural consolidations) and veins (femoral thrombosis) to complete the patient’s assessment, as an extension of the standard head-to-toe clinical examination. The combination of all the findings suggests pulmonary embolism as a possible diagnosis.

Focused cardiac ultrasound should always be done in a shocked patient, since it can reduce the range of differential diagnosis and identify the underlying pathophysiological mechanism of hypotension., A focused transthoracic echocardiogram has a high diagnostic and therapeutic impact, allowing diagnostic images in 84% of ventilated patients and 91% of spontaneously breathing patients, modifying the clinical management in 51.2% of cases.,,

Images alone allow the diagnosis of acute cor pulmonale, but not of pulmonary embolism unless they show a thrombus in the heart or in the pulmonary artery itself. However, Nazerian et al reported that the combination of acute failure of the right side of the heart, femoral thrombosis, and subpleural consolidations at ultrasound examination allows the diagnosis of acute pulmonary embolism with 90% sensitivity and 86.2% specificity. In contrast, the absence of acute cor pulmonale in a shocked patient rules out massive pulmonary embolism with a high negative predictive value (a sort of ultrasonographic D-dimer measurement). Finally, preexisting disease of the right side of the heart should always be ruled out,, (hypertrophic right ventricle with enlarged RA).

In Discussion Video 1, the right ventricle appears much wider than normal and is larger than the left ventricle, which is compressed; moreover, it is rounded. A normal right ventricle should be smaller than the left one, should be triangular, and should not compress the left ventricle at all (Discussion Video 2).

Discussion Video 3 shows a parasternal short-axis view with the typical D-shape: the high pressure in the right ventricle leads to compression of the left ventricle, which loses the rounded shape normally seen in this window (O-shape, Discussion Video 4), and becomes D-shaped. Notice the flattened septum and its paradoxical movement.

Discussion Video 5 shows a subcostal view with the same findings: the enlarged right side of the heart is compressing the left side of the heart, leading to reduced cardiac output due to a lower left ventricular preload.

Discussion Video 6 shows B-lines and subpleural consolidations, considered the lung ultrasound features of pulmonary embolism. Another ultrasound finding suggesting pulmonary embolism is the fixed, enlarged vena cava (Discussion Video 7).

Discussion Video 8 shows a thrombus in the left superficial femoral vein; veins normally appear anechoic and the probe should be able to compress them easily, as shown in Discussion Video 9.

After the focused echo examination, an angio-CT scan performed at 10 pm confirms the complete occlusion of the left main pulmonary artery and the right superior lobar pulmonary artery, with smaller but severe filling defects in the other branches on the right side.

In view of the critical clinical situation, the interventional radiologist is urgently called and angiography with selective mechanical thrombolysis is done (1 am).

This shows partial revascularization on the left side, but only poor results are seen on the right. The cardiac surgeon is prealerted at 1 am, but the patient suffers cardiac arrest in the angiography room and never responds to resuscitation maneuvers. She dies at 2 am, less than 12 hours after ED admission.

  • 1.

    Coexisting diagnoses in shocked patients are not uncommon; a focused echo examination helps distinguish the different causes of undifferentiated hypotension, frequently reorienting clinical management.

  • 2.

    Focused cardiac ultrasound diagnoses only acute cor pulmonale, not pulmonary embolism, unless there is an intracavitary thrombus or a thrombus in the pulmonary artery itself. In contrast, the absence of acute cor pulmonale in a shocked patient rules out massive pulmonary embolism, with a high negative predictive value.

  • 3.

    Point-of-care ultrasound can suggest the diagnosis of pulmonary embolism by combining multiple ultrasonographic findings. The concurrence of acute cor pulmonale, femoral thrombosis, and subpleural consolidations strongly suggests pulmonary embolism.

Financial/nonfinancial disclosures: None declared.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Nazerian P. .Vanni S. .Volpicelli G. .et al Accuracy of point of care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145:950-957 [PubMed]journal. [CrossRef] [PubMed]
 
Reza Ghane M. .Gharib M. .Ebrahimi A. .et al Accuracy of early Rapid Ultrasound in Shock (RUSH) examination performed by emergency physician for diagnosis of shock etiology in critically ill patients. J Emerg Trauma Shock. 2015;8:5-10 [PubMed]journal. [CrossRef] [PubMed]
 
Perera P. .Mailhot T. .Riley D. .Mandavia D. . The RUSH exam: Rapid Ultrasound in Shock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010;28:29-56 [PubMed]journal. [CrossRef] [PubMed]
 
Vignon P. .Chastagner C. .Francois B. .et al Diagnostic ability of hand-held echocardiography in ventilated critically ill patients. Crit Care Med. 2003;7:R84-R91 [PubMed]journal
 
Royse C. .Canty D.J. .Faris J. .Haji D.L. .Veltman M. .Royse A. . Core Review: Physician-performed ultrasound: the time has come for routine use in acute care medicine. Anesth Analg. 2012;115:1007-1028 [PubMed]journal. [CrossRef] [PubMed]
 
L’E Orme R.M. .Oram M.P. .McKinstry C.E. . Impact of echocardiography on patient management in the intensive care unit: an audit of district general hospital practice. Br J Anaesth. 2009;102:340-344 [PubMed]journal. [CrossRef] [PubMed]
 
Vieillard Baron A. .Prin S. .Chergui K. .Dubourg O. .Jardin F. . Echo-Doppler demonstration of acute cor pulmonale at the bedside in the medical intensive care unit. Am J Respir Crit Care Med. 2002;166:1310-1319 [PubMed]journal. [CrossRef] [PubMed]
 
Mayo P.H. .Beaulieu Y. .Doelken P. .et al American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135:1050-1060 [PubMed]journal. [CrossRef] [PubMed]
 
Azim A. .Rao P.B. .Srivastav P. .Singh P. . Cardiac tamponade mimicking septic shock diagnosed by early echocardiography. J Emerg Trauma Shock. 2010;3:306- [PubMed]journal
 
Beaulieu Y. . Specific skill set and goals of focused echocardiography for critical care clinicians. Crit Care Med. 2007;35:S144-S149 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Nazerian P. .Vanni S. .Volpicelli G. .et al Accuracy of point of care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145:950-957 [PubMed]journal. [CrossRef] [PubMed]
 
Reza Ghane M. .Gharib M. .Ebrahimi A. .et al Accuracy of early Rapid Ultrasound in Shock (RUSH) examination performed by emergency physician for diagnosis of shock etiology in critically ill patients. J Emerg Trauma Shock. 2015;8:5-10 [PubMed]journal. [CrossRef] [PubMed]
 
Perera P. .Mailhot T. .Riley D. .Mandavia D. . The RUSH exam: Rapid Ultrasound in Shock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010;28:29-56 [PubMed]journal. [CrossRef] [PubMed]
 
Vignon P. .Chastagner C. .Francois B. .et al Diagnostic ability of hand-held echocardiography in ventilated critically ill patients. Crit Care Med. 2003;7:R84-R91 [PubMed]journal
 
Royse C. .Canty D.J. .Faris J. .Haji D.L. .Veltman M. .Royse A. . Core Review: Physician-performed ultrasound: the time has come for routine use in acute care medicine. Anesth Analg. 2012;115:1007-1028 [PubMed]journal. [CrossRef] [PubMed]
 
L’E Orme R.M. .Oram M.P. .McKinstry C.E. . Impact of echocardiography on patient management in the intensive care unit: an audit of district general hospital practice. Br J Anaesth. 2009;102:340-344 [PubMed]journal. [CrossRef] [PubMed]
 
Vieillard Baron A. .Prin S. .Chergui K. .Dubourg O. .Jardin F. . Echo-Doppler demonstration of acute cor pulmonale at the bedside in the medical intensive care unit. Am J Respir Crit Care Med. 2002;166:1310-1319 [PubMed]journal. [CrossRef] [PubMed]
 
Mayo P.H. .Beaulieu Y. .Doelken P. .et al American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135:1050-1060 [PubMed]journal. [CrossRef] [PubMed]
 
Azim A. .Rao P.B. .Srivastav P. .Singh P. . Cardiac tamponade mimicking septic shock diagnosed by early echocardiography. J Emerg Trauma Shock. 2010;3:306- [PubMed]journal
 
Beaulieu Y. . Specific skill set and goals of focused echocardiography for critical care clinicians. Crit Care Med. 2007;35:S144-S149 [PubMed]journal. [CrossRef] [PubMed]
 
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