What would you do? Good Case

[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:

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[waterski232002]

What do you think the diagnosis is? How would you have managed and treated the patient?

 

[ThedarnmikeDO]

airway kit at bedside...what was his GCS...like 8?

 

[ThedarnmikeDO]

I think he is dissecting his thoracic aorta.

resus with fluids and blood. I'm concerned about his HR but if you were to drop it with esmolol you might take away all the cardiac output he has left perfusing his brain and kidneys.

RSI get an art line and send to OR stat.

 

[waterski232002]

His GCS was 14

 

[ThedarnmikeDO]

...and then the surgeons will laugh at me when they find his massive PE.

 

[WilcoWorld]

Echo for RV dilation - if I see it I'd push tPA (assuming no contraindications), as this patient appears to have hemodynamic instability secondary to a large PE.

 

[kungfufishing]

The U/S machine would provide the most rapid info.tamponade certainly not out of the question either.

 

[JkGrocerz]

Echo for RV dilation - if I see it I'd push tPA (assuming no contraindications), as this patient appears to have hemodynamic instability secondary to a large PE.

If your TTE is equivocal Would you still consider this knowing this pt is on coumadin and possibly therapeutic or supratherapeutic. I ask b/c if he's ruptured a AAA and you give him lytics you're fudged and I've looked for RV dilatation before, only to later realize that the abnormality was chronic.

too unstable for CT

got an ABG?

in addition to above, i'd type and cross ffp blood and platelets, get some o neg or type specific, rapid bedside u/s looking at aorta and FAST. if + transfuse with level one, speak to vasc surg and get to OR.

i've also would have intubated this guy at the door

 

[EdEmEr]

If he responded well to the 02 NRB couldn't you argue that the pulmonary circuit is fine and the fact that he: failed the fluid challenge, is still hypotensive and tachy, and has a wide mediastinum would lean towards the dissection. Though he is a little on the young side.

I would be doing any ultrasound study I could while calling the surgeons. Would an abdominal pick up a strangulated hiatal hernia?

Sounds like he needs to get intubated ASAP.

++add esophageal tear/rupture to my diff

 

[tegs15]

It must be ANTHRAX until proven otherwise!

 

[southerndoc]

I would consult cardiothoracic surgery immediately and probably vote that the patient goes to the OR either for emergent embolectomy, repair of his thoracic dissections, or repair of his Boerhaave's esophagus.

Given the findings of the widened mediastinum and pleural effusion, I would vote for a dissection or Boerhaave's, although both of these usually involve left pleural effusions instead of right effusions.

 

[nachoDoc]

I would consult cardiothoracic surgery immediately and probably vote that the patient goes to the OR either for emergent embolectomy, repair of his thoracic dissection.

R/o Dissecting aortic embolism CT team STAT prep for OR.

 

[a_ditchdoc]

I know the guy is unstable, but I would stronlgy consider a CT after intubation. He probably needs surgery, but blind dissection doesn't sound all that favorable. Boerhaaves and dissecting aorta sound like the top two candidates. Isn't an effusion associated with Boerhaaves?

 

[WilcoWorld]

At this point 33% vote to await labs? This patient needs stabilization!

 

[waterski232002]

For the answer to what was actually done, and for case follow-up... see the new thread "What would you do? Good Case (part 2)"

 

[Seaglass]

Would intubate, bedside echo for RV dilation. Wide mediastinum on PCXR = poop. Right pleural effusion does not go with boorhaves or leaking dissection - those should be left effusions. Also dissection does not go with hypoxia, Boorhaves can but less likely. Most probable Dx is large PE given known DVTs.

 

[southerndoc]

Would intubate, bedside echo for RV dilation. Wide mediastinum on PCXR = poop. Right pleural effusion does not go with boorhaves or leaking dissection - those should be left effusions. Also dissection does not go with hypoxia, Boorhaves can but less likely. Most probable Dx is large PE given known DVTs.

Effusions can cause hypoxemia, and dissections can cause effusions. Therefore, a dissection can cause hypoxemia.

You are right that Boerhaave's and dissections usually present with left pleural effusions, but does this mean they absolutely cannot present with a right pleural effusion?

 

[Seaglass]

There are, of course, no absolutes.

 

[ccfccp]

At this point 33% vote to await labs? This patient needs stabilization!

I can just see John Ritter's family (and attorney) lining up again...

 

[canjosh]

R/o Dissecting aortic embolism CT team STAT prep for OR.

EEK! His embolism is dissecting!!