You got stuck with another holiday shift. As usual it starts off slow, but eventually a bolus of patients arrives, to make up for lost time and then some. Fortunately most of your patients aren’t that sick. Many are visiting from out of town and staying with family. Some forgot their medications on the other side of the country and so their blood pressure or chronic pain or – fill in the blank – is out of control. Some would have seen their regular doctor for their admittedly minor issue, but alas, it is the holidays and everything is closed or booked. As you sort through tonight’s patients – and their emptied rooms are all too quickly refilled – you eventually meet someone who actually, desperately, needs your help.
He is a lethargic and slightly hypotensive 38-year-old male with a history of diabetes, hypertension, hepatitis C, cirrhosis and methamphetamine abuse who is brought in by family for trouble breathing and weakness that has progressively worsened over the past 24 hours. Though he doesn’t give much history himself, his family states he had been complaining of some chest pain as well. There has been no fever, vomiting, diarrhea, cough or other problems, and he has never had this constellation of symptoms before.
On exam you note that he is somewhat lethargic, answering questions with little more than a yes or a no. His vital signs are all normal except for his blood pressure, which is 83/41 mmHg. Though he is short of breath, his pulse ox is actually normal at 98% on room air. His head and neck exam is remarkable for somewhat dry mucosa coupled oddly enough with a bit of JVD. His lungs sound clear, but he is slightly tachypneic. His heart has a noticeable systolic ejection murmur which is new per family, although they admit they can’t be completely certain. His abdomen is non-tender and he has no appreciable peripheral edema.
Testing shows diffuse anterior ST depression on EKG, and cardiomegaly without infiltrates on chest X-ray. His white blood cell count is elevated at 15, his troponin and creatinine are both 2.3, his BNP is 540 and his lactate level is 5.5. The rest of his chemistries and other lab tests show more abnormals than normals. Seeing that you are obviously dealing with a sick patient you get on the phone with the hospitalist to admit the patient to the ICU and the cardiologist to see if he wants to take the patient to the cath lab or approve a stat echocardiogram. Unfortunately, it’s late at night and it’s also a holiday.
The cardiologist recommends cautious fluid resuscitation and pressors if necessary. They can do an echocardiogram early the next morning. You feel a bit uncomfortable with the recommendations as you are not sure what is causing this patient’s hypotension and you worry about a cardiac cause since there is a new murmur on exam. However, it is late and your consultant is the chief of cardiology, and most importantly he has a number of recommendations which are sound. This could after all be sepsis, or a PE or dehydration or something else. And even if it is cardiac, there is no ST-elevation and no one is going to come do an emergent valve repair in a patient in the middle of the night, especially if you haven’t even really done much yet to try to stabilize him medically.
You decide not to fight this battle, and take care of this patient the best you can without having the echo tech called in for a stat afterhours study. Then you graciously thank your consultant, hang up the phone and fire up the ED ultrasound machine to take a look yourself.
What various conditions should you be looking for and what would they look like on bedside ultrasound? Of these, which is seen on the parasternal view of the heart below?
Continue to next page for the conclusion