Hypotension case 4

Hypotension case 4


A 63-year-old man is brought into the emergency department with shortness of breath over the past 4 hours, although the patient's family
states that he had complained of some shortness of breath and dry cough over the past 2 months. The patient denies any significant past medical history, fever, chills, or chest pain, and has not been taking any medications. Review of systems is positive for a 10 pound weight loss
in the last 5 months and social history pertinent for a 20-pack-year smoking history, but the patient had quit smoking 10 years prior. Physical examination reveals a thin man who is alert and awake but in obvious distress and breathing shallowly. His temperature is 37.2 C (99 F),
blood pressure is 90/75 mm Hg, pulse is 122/min, and respirations are 20/min. The neck veins are prominent with a decline during inspiration.
The cardiac examination is significant for tachycardia and distant heart sounds, but no murmurs/gallops/rubs are heard. Lung examination is significant for decreased breath sounds at the bases, but no crackles or wheezes are heard. No peripheral edema is seen. Labs are sent.
ECG reveals a sinus tachycardia at 118/min, Iow voltage QRS complexes, and electrical alternans of the P, QRS, and T waves. A chest x-ray
film shows an enlarged cardiac silhouette, but minimal pulmonary vascular congestion.


Q 1
Which of the following is characteristic of the patient's condition?
/ A. Pulsus alternans
/ B. Pulsus bisferiens
/ C. Pulsus et tardus
/ D. Pulsus paradoxus
/ E. Quincke's pulses


Q 2
Which of the following features on the echocardiogram would be diagnostic?
/ A. Anterior wall hypokinesis
/ B. Collapse of the right ventricle during diastole
/ C. Diastolic dysfunction
/ D. Left ventricular hypertrophy
/ E. Pericardial fluid collection



Q 3
Which of the following is the most appropriate immediate treatment for this patient?
/ A. Antibiotics
/ B. Diuresis
/ C. Heparin
/ D. Pericardiocentesis
/ E. Pericardial window



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Hypotension case 4 answers


A1
The correct answer is D. This patient has cardiac tamponade. This disorder is characterized by elevation of intracardiac pressures, limitation of ventricular filling, and reduction of cardiac output. The patient's presentation is highly suggestive of this disorder, with dyspnea, tachycardia, hypotension, neck vein distention with pulsations, and muffled heart sounds. Severe, acute tamponade is characterized by falling arterial pressure, and rising venous pressure, but slowly developing tamponade may resemble congestive heart failure. The jugular venous pressure shows a prominent x descent; in constrictive pericarditis, the y descent is prominent. The ECG in tamponade tends to show tachycardia, but with small QRS complexes because the pericardial fluid hinders the transmission of the impulses. Electrical alternans (beat-to-beat alternation in ECG components) of the P, QRS, and T waves is suggestive of effusion, often with tamponade. The chest x-ray film tends to show a globular heart, but minimal pulmonary edema. Pulsus paradoxus can be present in patients with cardiac tamponade. It is present if a > 10 mm Hg decline in systolic pressure is measured during inspiration, and is caused by impaired left ventricular filling.
Pulsus alternans (choice A) is a regular alteration in pulse pressure amplitude in severe left ventricular dysfunction.
Pulsus bisferiens (choice B) refers to two palpable peaks in the pulse of those with mixed aortic regurgitation and stenosis and hypertrophic obstructive cardiomyopathy.
Pulsus et tardus (choice C) is a delayed carotid upstroke seen in aortic stenosis.
Quincke's pulses (choice E) are subungual capillary pulsations seen in patients with aortic regurgitation.


A2
The correct answer is B. A patient with cardiac tamponade has pericardial effusion (choice E) on echocardiography, but right ventricle/atrium collapse during diastole is specific for tamponade. Patients with pericardial effusion only (no tamponade) can be asymptomatic.
Anterior wall hypokinesis (choice A) can occur in patients with anterior myocardial infarction.
Diastolic dysfunction (choice C) is impaired right or left ventricular filling from long-standing hypertension.
Left ventricular hypertrophy (choice D) is enlargement of the left ventricular wall, often from hypertension.


A3
The correct answer is D. The most immediate treatment for this disorder is pericardiocentesis (placing a needle into pericardial space to aspirate fluid) if a patient shows any signs of hemodynamic compromise.
Antibiotics (choice A) are not indicated unless there are any other signs of infections.
Diuresis (choice B) is important for heart failure, but is not appropriate for this patient with pending cardiovascular collapse if not treated.
Heparin (choice C) is used for anticoagulation for pulmonary embolus and deep vein thrombus.
Pericardial window (choice E) is used in chronic pericardial effusion and constrictive pericarditis to drain the recurrent fluid accumulation.