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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Case 11
Chief Complaint
“I can’t breathe so well.”
History and Physical Examination
A 56-year-old man is in a motor vehicle accident and sustains chest wall trauma. He is
brought to the emergency department an hour later with shortness of breath. He is
generally healthy. He takes no medications and has no drug allergies.
He is afebrile. BP is 114/70 mm Hg, pulse 118/min, and respirations 26/min. Physical
examination reveals chest contusions visible over the sternum and several tender ribs.
Jugular venous distention is noted.
Differential Diagnosis
Initial Management
Setting: emergency department
Diagnostic/Therapeutic Plan
Pneumothorax1.
Congestive failure2.
Tamponade3.
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Test Results
Assessment
Tachycardia, hypotension, and distended neck veins are the signs of cardiac tamponade. The
compression of the heart will cause decreased cardiac output and the backup of blood into the
neck veins. BP will drop on inspiration normally; this drop in BP is exaggerated in cardiac
tamponade.
A drop in BP on inhalation >10 mm Hg is called ‘pulsus paradoxicus.’ It is a ‘paradox’ because
when BP drops below 90 mm Hg, the radial pulse will disappear. This is the paradox: the
pulse disappears but the patient is still alive.
Tamponade is associated with pulsus paradoxicus. Constrictive pericarditis is associated with
Kussmaul sign. Kussmaul sign is an increase in jugulovenous pressure on inhalation. Chest
wall trauma can cause tamponade. Anything that causes pericarditis can cause tamponade if
there is enough extravasation of fluid into the pericardial space to compress the heart.
Normal saline bolus
Oxygen
Chest x-ray
Oximeter
Electrocardiogram
Arterial blood gases
Chest x-ray: rib fractures, no infiltrates
Oximeter: 93% saturation on room air
Electrocardiogram: sinus tachycardia; QRS complexes vary in size from beat to beat
Arterial blood gases: pH 7.53, pCO2 24, pO2 74
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The variation in the height of the QRS from beat to beat is called ‘electrical alternans.’ It is
from the heart flopping backward and forward in the chest.
Further Management Plan/Results
Assess pulsus paradoxicus Systolic BP drops 20 mm on inhalation
Echocardiogram Diastolic collapse of right atrium and right
ventricle
Discussion
Cardiac tamponade is an emergency. Compression of the right side of the heart occurs first
because the walls of these chambers are thinner than those on the left side of the heart. Death
occurs from hypotension. Needle decompression of as little as 50–100 mL of fluid can be life-
saving.
Diuretics should not be given because they decrease right ventricular filling pressure and can
make the collapse of the right side of the heart even worse. Occasionally, a right-sided
catheterization is performed. There is equalization of pressures in all 4 chambers of the heart in
diastole.
Follow-up Management and Prevention
Final Diagnosis
Continue IV normal saline
Pericardiocentesis with a needle
Possible placement of a pericardial window
Surgical consultation
Transfer to ICU
173
Cardiac tamponade
CLINICAL PEARL
Tamponade
Pneumothorax
Pericarditis
Jugular venous distention, hypotension, tachycardia
Pulsus paradoxicus
Electrical alternans on electrocardiogram
Right atrial and ventricular diastolic collapse on echocardiogram
Distended neck veins
No pulsus paradoxicus
Visible on chest x-ray
Needle or chest tube decompression
Chest pain that changes with respiration and position
ST elevation everywhere on electrocardiogram
PR segment depression
Treat with NSAIDs; if no response, use steroids
Use colchicine to prevent recurrences
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175
Case 12
Chief Complaint
“I passed out.”
History and Physical Examination
A 72-year-old man comes to the emergency department with an episode of syncope lasting
<10 minutes, witnessed by his family. He was getting up from a seated position and
started to play with his grandson when he suddenly lost consciousness. Within 5 minutes
of hitting the floor, he fully regained consciousness. He denies a history of dyspnea and
chest pain.
BP is 110/88 mm Hg, pulse 96/min, respirations 18/min. There is no fever. Chest is clear
to auscultation. Cardiovascular exam reveals III/VI murmur at the second upper right
intercostal space. The murmur radiates to the carotid arteries. The murmur is worse with
leg raise and squatting and better with Valsalva. HEENT reveals a diminished carotid
upstroke. On the exterior, no edema is found.
Initial Management
Setting: emergency department
Diagnostic/Therapeutic Plan
IV normal saline
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Test Results
Assessment
The most important element of the evaluation of syncope is to exclude cardiac ischemia or
arrhythmia as the cause. The majority of the mortality is associated with cardiac syncope; that
is why an electrocardiogram, cardiac enzymes, and telemetry monitoring are done in almost all
cases. Ventricular arrhythmia leads to syncope and cardiac ischemia is the most common cause
of arrhythmia.
It is important to determine the following 3 things.
Oxygen
Oximeter
Electrocardiogram
Telemetry monitoring
CK-MB and troponin
Oximeter 97% room air saturation
Electrocardiogram: SV1 and RV5 >40 mm
No ST changes—
T-wave inversions in lateral leads that are old—
Telemetry monitoring unrevealing so far
CK-MB and toponin normal
Did the loss of consciousness occur suddenly?
Sudden loss means a cardiac or neurologic abnormality
1.
Did the regaining of consciousness occur suddenly?
Sudden regaining means a cardiac problem
2.
177
In this case, even before a single test is done, we know the origin of the loss of consciousness
has to be cardiac. In addition, the murmur heard at the right second intercostal space has to be
AS.
Also, with AS:
Further Management Plan/Results
Transthoracic echocardiogram Severe AS, valve diameter 0.8 cm
2
Stress (exercise tolerance) test Normal
Discussion
AS most commonly presents with chest pain because 50-70% of patients have coronary
disease. This high frequency of ischemic heart disease is why all patients with AS should have
coronary ischemia excluded. In addition, since surgical valve replacement is the number 1
treatment, as long as the patient’s chest will be cracked open, be sure there is no coronary
disease (because it makes sense to do bypass surgery at the same time if there is 3-vessel or
left main coronary disease).
Anyone with symptomatic AS needs valve replacement. After chest pain, the next most common
symptoms are syncope and dyspnea. Balloon dilation is not as good as valve replacement.
Balloon dilation is only done in those for whom surgery cannot be done.
Is there a murmur on exam?
An abnormal exam means aortic stenosis (AS), HOCM, or mitral stenosis
3.
There is an association with a decreased carotid upstroke and the signs of left ventricular
hypertrophy on electrocardiogram (found here)
Murmur decreases in intensity with Valsalva and standing position
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CLINICAL PEARL
Aortic stenosis should be distinguished from HOCM.
Follow-up Management and Prevention
Final Diagnosis
Syncope due to aortic stenosis
Syncope, dyspnea and chest pain
Systolic murmur better with squatting and leg raise
Diagnose with echocardiogram
Treat with beta blocker or verapamil
Catheter decompression with alcohol infusion or surgical myomectomy
Cardiology evaluation
Cardiothoracic surgery evaluation
Valve replacement surgery
179
4
Pulmonology
Case 1
Chief Complaint
Increasing shortness of breath with cough and wheezing
History and Physical Examination
A 24-year-old woman comes to emergency department during wintertime with severe
shortness of breath for 2 to 3 days. Her family states that she has a history of asthma and a
chronic “nasal stuffiness.” She has been maintained on bronchodilators and steroid
inhaler. She recently developed an upper respiratory infection and began to mildly
wheeze. She has been taking an over-the-counter cold medicine over the last day. This
afternoon she developed acute worsening of her breathing and called 911.
She has low grade fevers (Tmax 100.4). Her BP is 180/100 mm Hg, pulse 120/min, and
respirations 36/min. The patient appears agitated, restless, and is unable to speak in full
sentences. She is using accessory muscles to breathe. Physical exam shows discharge
from a nasal polyp. She has a paradoxical pulse with inspiration; no jugular venous
distention is noted. Pulmonary exam shows minimal breath sounds, and faint expiratory
wheezes are heard throughout with prolonged expiratory phase. The heart is tachycardic,
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