Set #1: Shock diagnosis
Question 1: You are called to evaluate a patient in the emergency department with a terrifyingly huge pulmonary embolism on CT scan. The patient is a previously well 49 year old woman who developed severe gastroenteritis three days ago. She was having difficulty maintaining oral intake so she presented to the emergency department. In the ED, she was noted to have the following parasternal long-axis echocardiogram:
Based on this echocardiographic finding, she was sent for a CT angiogram which confirmed a saddle pulmonary embolism. You were called immediately after this resulted. Her current vital signs are:
- Heart rate 125 b/m
- Bp 97/63
- Respiratory rate 28 b/m
- Temperature 38 C
- Saturation 97% on four liters nasal cannula oxygen
She looks anxious but is mentating normally and in no substantial distress. You assess her hemodynamics and find her IVC to appear as shown here:
How would you manage this patient? She has no contraindication to thrombolysis.
Question 2: You are called upon to evaluate a patient with stage IV breast CA who presented to the ED with dyspnea and shock (Hr 140, Bp 85/68, Resp rate 35). An electrocardiogram is performed which is shown here:
Bedside echocardiography is performed with results shown here:
What is her shock index?
What is the best next management step?
- DC cardioversion.
- Intubation to facilitate surgical pericardial window.
- Load with two liters of crystalloid.
- Bedside pericardial drainage.
- Obtain a STAT complete bedside echocardiogram.
You are called upon to evaluate a 25-year-old man who presented to the emergency department with shortness of breath and a fever. He has no known prior medical history. He is a millennial artist who is living with his parents in Rutland, Vermont. Examination reveals a underweight man with mild respiratory distress and the following vital signs:
- Heart rate 139 b/m
- Bp 105/53
- Respiratory rate 34 b/m
- Temperature 39 C
- Saturation 97% on six liters nasal cannula oxygen
Lung ultrasonograhy on both sides of the anterior chest shows the following pattern:
which type of shock is most likely in this patient?
- Septic shock
- Cardiogenic shock
- Pericardial tamponade
- Pulmonary embolism
- Hypovolemic shock
A 23-year-old woman who is a student at UVM medical school presents with shortness of breath on exertion. Symptoms have been progressing over the past few days. She uses Plan-B oral contraception on a PRN basis. Review of systems is also notable for a sore throat and vesicles on her hands and feet. Vital signs are:
- Heart rate 143 b/m
- Bp 91/75
- Respiratory rate 29 b/m
- Temperature 37.1 C
- Saturation 91% on room air
Her labs are significant for a creatinine of 1.3 mg/dL (no prior baseline). Her transthoracic echocardiogram is as follows:
Her IVC has the following appearance:
Her lung ultrasonography shows the following pattern bilaterally:
Which of the following is the most reasonable therapy?
- Fluid challenge
- Milrinone infusion
- Thrombolysis (100 mg alteplase)
Set #2: Shock diagnosis… extreme
Question 5: A 70-year-old woman presents with sudden-onset chest pain. Her past medical history is notable for hypertension and hyperlipidemia. She undergoes an evaluation for myocardial infarction, which shows a negative troponin and nonspecific changes on EKG. She is still looking unwell, so she gets a D-dimer checked which is elevated at 980. This triggers a CT angiogram of her chest, which is negative for pulmonary embolism. Following return from CT scan she rapidly deteriorates with the following vital signs:
- Heart rate 127 b/m
- Bp 100/43
- Respiratory rate 32 b/m
- Temperature 37.1 C
- Saturation 92% on room air
Her echocardiogram reveals the following:
You are considering placing a central line, so you ultrasound her neck. You find the following structure in her neck:
What is the most appropriate next management or diagnostic step for this patient?
Question 6: A 39-year-old man presents with hypotension and probable pneumonia (fever, sputum production, CXR with new lobar infiltrate, leukocytosis). He has a history of hypertrophic obstructive cardiomyopathy (HOCM), with records which aren't immediately available. While in the emergency department he develops worsening respiratory failure and hypoxemia. He is treated with norepinephrine, but this causes no improvement in his blood pressure. Vital signs are as follows:
- Heart rate 145 b/m
- Bp 90/71
- Respiratory rate 36 b/m
- Temperature 39 C
- Saturation 92% on six liters nasal cannula.
You are called to evaluate the patient because he apparently has vasopressor-refractory septic shock. Currently his norepinephrine is titrated up to 30 mcg/min and it doesn't seem to get any traction on his blood pressure. Echocardiography reveals the following findings:
The IVC looks like this:
Please discuss further management for this patient:
- What is causing him to be refractory to vasopressor?
- What maneuvers can be used to stabilize his hemodynamics?
- What effect would intubation probably have on his blood pressure?
Question 7: A elderly and very frail patient with advanced COPD and an FEV1 of 15% was found to have a right-sided lung mass. Although she isn't a candidate for any sort of therapy, she receives a transthoracic needle biopsy because she wants to know what the diagnosis is. Following the biopsy, she deteriorates with tachypnea, hypotension, and right-sided chest pain. Her vital signs are:
- Heart rate 123 b/m
- Bp 93/74
- Respiratory rate 27 b/m
- Temperature 37.2 C
- Saturation 92% on four liters nasal cannula.
Ultrasonography of her left anterior thorax shows the following:
Ultrasonography of her right anterior chest wall shows this:
Ultrasonography a bit laterally along her chest wall, in the mid-axillary location reveals this:
Ultrasonography at the right lung base shows the following:
- This combination of ultrasound images is diagnostic of what diagnosis? Please be as precise as possible.
- What are the next steps in her management?
Question 8: A 85-year-old woman presents with sudden onset dyspnea. She reports that she has been a bit “under the weather” for the past few days, not feeling right with some low-grade fevers. While gardening today she noticed rapid onset of dyspnea with some mild diaphoresis. Laboratory studies are notable for a troponin of 43 with the following EKG:
Her lung ultrasound shows the following pattern throughout her anterior chest:
Her echocardiogram shows the following:
What is your diagnosis? What is the next step for this patient's management?