Case 43

66 yo F pmh Parkinson's and developmental delay BIBEMS for respiratory distress. Pt found to be hypoxic, hypotensive and tachycardic on arrival.  Pt previously well without illness per family at the bedside acting at baseline yesterday.  No further information available 2/2 patient's developmental delay.

PE:
Initial vital signs:  T 99 R  HR 137 RR 26 BP 78/42  O2 sat 87% nonrebreather

Constitutional: Well developed, well nourished tachypneic female

Skin: no acute rash

Head: NCAT

Eyes: PERRL, EOMI, clear conjunctiva and sclera

ENT: no nasal discharge, airway clear

Neck: supple, nontender

Cardiac: S1S2 tachycardic.  no murmurs/rubs/gallops

Respiratory: tachypneic, clear to auscultation bilaterally

Abd: normal bowel sounds. diffuse tenderness to palpation. no guarding.

Neuro: alert

QUESTIONS:

  1. What do the ultrasound clips show? 
  2. What is the differential diagnosis?
  3. What are treatment options?

 

ANSWERS:

  1. 43a is an apical 4 chamber view.  43b is a slightly rotated A4 view with the septum pointing towards the right side of the screen. Both views show a dilated right ventricle with right heart strain.
  2. Causes of right heart strain include pulmonary embolism, pulmonary hypertension, pulmonary valve stenosis, tricuspid regurgitation, and left-to-right shunts.
  3. In this hemodynamically unstable patient, first attend to ABCs. Place patient on NIPPV and/or prepare to intubate if necessary. Fluid bolus 20cc/kg. Evidence of right ventricular overload on ultrasound with high suspicion for PE is an indication to start thrombolytic therapy (unless otherwise contraindicated). Thrombolytics can include IV TPA or catheter-directed embolectomy performed by interventional radiology.