What would you do? Good Case (Part 2)

[waterski232002]

55 yo healthy M presents to ER c/o sudden onset sharp epigastric pain and SOB 2 hours ago in extremis. He is weak and has extremely labored breathing. 36.7, 53/25 140 50 67% RA. His history includes DM, HTN, Bilateral LE DVTs on coumadin.

Pt placed on NRB with O2 sat >90%
RN failed multiple pIV attempts
Resident places R fem Central Line
2 liters NS IV bolus
Dexi 167
EKG - Sinus Tach
CXR - Mod wide mediastinum, Mod R effusion (portable)
Vitals - 84/36 130 40 95% NRB

What would you do next: --> See choices/discussion from previous thread "What would you do? Good case"

----------------------- UPDATE --------------------------

Cardiology fellow was called to the bedside to perform STAT Transthoracic Echo. They were in the ED within 10 minutes and the preliminary finding was elevated RV pressures in the mid 40's. No tamponade. Unable to definitively say if there was acute RV strain. Recommended pushing TPA if clinically indicated, but not based on Echo results. ER US for AAA performed and unable to visualize aorta due to pt obesity.

CBC - WBC 17.5, Hgb 9.3 (12.3 3-months ago), plts 108
BMP - Cl 109, Bicarb 16, BUN 21, Cr 1.8, Gluc 240
LFTs - Normal
Lipase - Normal
CE - mildly elevated troponin 0.32 (normal < 0.10)
BNP - 193
Coags - INR 2.8
Lactate - 3.2
VBG - pH 7.26, SvO2 31

Guaiac mild pos, no gross blood, no melena
T+C for 2 units pRBCs called for
Liters 3 & 4 NS infusing
GCS 15
Patient feeling markedly better, still mild SOB and epigastric pain.
Abdomenal exam soft and benign
98/50 110 26 98% NRB

What would you do next?

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[nachoDoc]

CE - mildly elevated troponin 0.32 (normal < 0.10)
What would you do next?

I'm sticking with Type A, Debakey I/II AAA based on his troponin and clinical status. If he blows, there he goes... CT team!

When the SVO2 is less than 30%, tissue oxygen balance is compromised, he's had 3l fluid, bp still low. While waiting on the CT team, get the CT chest/abd going.

 

[BADMD]

Looks like this guy is responding to resuscitation, so we have a region of stability and don't need to shoot from the hip.

I'd grab a CVP, realizing the limitations of a fem line for that., and continue resuscitation. That SvO2 of 31 is concerning, to say the least. PE, Dissection and esophageal rupture still need to be be ruled out, but this guy could just be septic from a pneumonia. It doesn't sound like there is anything going on in the belly, but there still could be some retroperitoneal free air or even blood. I'd run this guy, shoulders to hips, in the CT scanner, with IV contrast, while I watch from the console for trouble. I'll throw some bicarb in the mix for renal protection, but I suspect that his kidneys have already taken the hit. An ABG would be helpful to see how much of a V/Q mismatch we're actually looking at.

I'd be afraid to try and sedate this guy for a TEE. Plus, at my place, I'm not sure how fast I can get one.

Since he isn't biting the plastic cigar, I'd like to try and get a little more history and see if something is going to point me in the right direction while I wait for the CT to become available.

 

[southerndoc]

With his pressure being what it is now, I would get a peripheral IV and wisk him to the CT scanner for a dissection protocol (chest/abd/pelvis at my institution). (The peripheral IV is to inject the contrast, unless your femoral central line is an introducer [Cordis] and not a triple lumen catheter.)

I would hold off on the aspirin, heparin, etc. until the CT. Again, I would want CT surgery at the bedside immediately.

I'm still going with Boerhaave's or thoracic dissection.

Regarding the troponin, PE can give you a positive troponin with severe right heart strain. However, if he had ACUTE severe right heart strain, I would expect his 12-lead to show more than just sinus tachycardia. Does the patient have evidence of right heart strain?

Finally, it is difficult -- although not impossible -- to have a PE with an INR of 2.8.

 

[EdEmEr]

Get thee to tomagraphy!!

If he does have a rupture/dissection and is bleeding into a cavity (mediastinum/thorax etc), is the contrast laden blood a concern? If PE is number three down the list I would worry about the kidneys in a sicko who is going to surgery/sicu or in a best case scenario the micu. I would ask rads if they really really need the contrast.

I would have my intern follow him to CT with the crash cart. Oh wait!!! I will be the intern. Crap

 

[waterski232002]

Regarding the troponin, PE can give you a positive troponin with severe right heart strain. However, if he had ACUTE severe right heart strain, I would expect his 12-lead to show more than just sinus tachycardia. Does the patient have evidence of right heart strain?

Finally, it is difficult -- although not impossible -- to have a PE with an INR of 2.8.

The EKG has a R axis and S1Q3TWI3.... but so does the last EKG from 3 months ago. It's essentially unchanged except the rate. Regarding the femoral line... it was a triple lumen. Later the nurses were able to gain peripheral access as well.

 

[southerndoc]

The EKG has a R axis and S1Q3TWI3.... but so does the last EKG from 3 months ago. It's essentially unchanged except the rate. Regarding the femoral line... it was a triple lumen. Later the nurses were able to gain peripheral access as well.

Why a triple lumen? Does your hospital not allow you to place introducer sheaths, or did you think he was septic when he presented? (I've heard rumors that some hospitals won't allow ED physicians to place introducer sheaths, which I find appalling.)

 

[nachoDoc]

The EKG has a R axis and S1Q3TWI3.... but so does the last EKG from 3 months ago. It's essentially unchanged except the rate. Regarding the femoral line... it was a triple lumen. Later the nurses were able to gain peripheral access as well.

His Hb is down and absent any ST elevation or evidence of acute MI, an elevated Troponin is consistent with Type A dissection. He's leaking so keep his pressure down and prep for the CT guys.

 

[waterski232002]

The working diagnosis was massive PE due to acute onset and impressive tachycardia/hypoxia. Central line was placed for immediate access and IVF, not for suspected hemorrhagic shock (although definitely high on the differential... AD, retained retroperitoneal ruptured AAA, posterior MI, massive GIB). Sepsis was not really a concern given the sudden onset of symptoms.

I've never heard of an ER where cordis placement is off limits. If those limitations exists, that is a major liability. I would hate to resuscitate a dying trauma patient, hemorrhaging ectopic, or massive GIB without a cordis, or manage a complete heart block without the ability to transvenous pace. I'd hate to be the patient that showed up to that ER even more!

 

[waterski232002]

His Hb is down and absent any ST elevation or evidence of acute MI, an elevated Troponin is consistent with Type A dissection. He's leaking so keep his pressure down and prep for the CT guys.

This is absolutely not true. There are many reasons a troponin can be elevated in the absence of STEMI (pericarditis, anemia, demand ischemia, renal failure, PE with RV strain, lab error, to name a few). You are right that Aortic Dissection can cause an elevated troponin, but generally it would be due to demand ischemia or dissection involving the coronary arteries. However, if the coronary arteries were dissected, one would expect the EKG to show ST elevations rather than sinus tach.

 

[nachoDoc]

This is absolutely not true. There are many reasons a troponin can be elevated in the absence of STEMI (pericarditis, anemia, demand ischemia, renal failure, PE with RV strain, lab error, to name a few). You are right that Aortic Dissection can cause an elevated troponin, but generally it would be due to demand ischemia or dissection involving the coronary arteries. However, if the coronary arteries were dissected, one would expect the EKG to show ST elevations rather than sinus tach.

Yes, but it was because there was no evidence of cardiac ischemia and Sinus Tach that it would be consistent with AD. We agree.

 

[EdEmEr]

His Hb is down .

More likely chronic don't you think? Dissection wouldn't drop his H/H acutely.

 

[waterski232002]

Yes, but it was because there was no evidence of cardiac ischemia and Sinus Tach that it would be consistent with AD. We agree.

Not to be critical, but we don't agree.

I'll let others elaborate or weigh in if they feel so compelled, but I think you missed my point above. A mildly elevated troponin would not raise or lower my suspicion for aortic dissection (it would be an extremely rare cause of an elevated troponin). I would more likley attribute it to non-specific demand ischemia from a HR of 140 in a man with multiple known CAD risk factors (age, HTN, DM), and I would look closely at the EKG to make sure I didn't miss a subtle inferior/posterior infarct... especially given his presentation with significant hypotension which was responsive to IVF.

FYI... the 2nd EKG done 2 hours later looked the same as the first, except slower rate.

That being said, I do agree that Aortic Dissection is definitely still a major concern and high on the differential (although irrespective from the troponin).

 

[Seaglass]

^^ What he said.

 

[Seaglass]

PE still the major dx on the differential. Dissection still doesn't explain the hypoxia.

 

[southerndoc]

PE still the major dx on the differential. Dissection still doesn't explain the hypoxia.

Effusion from a dissection can explain hypoxemia.

 

[nachoDoc]

Do we have the CT results yet?

 

[plasticcigar]

i would probably do a thorough physical exam next. maybe even get more of a history.

 

[kungfufishing]

also a rapid strep screen (that is sarcasm)

since you seem to be headed for PE, perhaps this ends up being something else since why post it on the internet otherwise? What did the scan show?

 

[CueDoc]

Can we get a d-dimer in addition to the rapid strep?

 

[southerndoc]

Can we get a d-dimer in addition to the rapid strep?

 

[nachoDoc]

Should be interesting. Hope it's not like: Post coital aortic dissection: a case report, Journal of Medical Case Reports 2008, 2:6 or another John Ritter posit.
*calls rad for CT results*

 

[waterski232002]

For the Final Answer see New Thread "What would you do? Good Case (Part 3)"