Ching Jane Ko

1/1 Assessments Completed

Case Study 2

Clinical Scenario
Mr C is 60 years old and has presented to the Emergency Department with acute

shortness of breath. A chest Xray shows widespread bilateral shadowing that is

non- specific.

He is an insulin-dependent diabetic and has been unwell for the last week. For the

last 24 hours he has been coughing up copious sputum that he described as

“white”. His temperature was 38.5°C.

Blood pressure in the emergency department was 100/50mmHg. His pulse rate

was 95bpm with a small arterial pulse volume clinically.

Usual medication includes insulin, ACE inhibitor, frusemide and simvastatin.

He is known to have ischaemic heart disease and underwent coronary artery

stenting two years ago. An echocardiogram 10 months ago was reported as

demonstrating normal LV systolic function.

His respiratory status deteriorated and he required emergency intubation and

ventilation. A TOE was performed.

Observe the following echocardiography images and videos.

0:01 -0:01

ME four chamber view

0:00 -0:00

ME AV SAX view

0:00 -0:01

TG Basal SAX view

TG mid SAX view

Estimate of RA area

Transmitral spectral Doppler

Pulmonary vein flow spectral Doppler

PW Doppler in the LVOTPlease use LVOT dimension of 2.0cm for calculations.

Quiz MANDATORY

What is your differential diagnosis?

Write a summary of the important diagnostic clinical and TOE features.
Write your final diagnosis and describe your management strategy.

Heart failure with APO

EXPLANATION

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Solution

Differential Diagnosis
Acute myocardial infarction

Pulmonary oedema

Bilateral pneumonia

Acute aspiration pneumonitis

Summary of the Important Diagnostic Features

The left ventricle is severely dilated with extensive hypo/akinesia and severe systolic
dysfunction.
The cardiac output is 3.1L/min (HR 54bpm), which is low in this patient.
RV systolic motion is normal.
There is a high LAP state suggested by the fixed curvature of the interatrial septum.
The echo appearances indicate that the LV dysfunction is a major cause of the hypotension. The
echo does not help in determining whether the impairment is acute or longstanding.

The bilateral lung changes could be cardiogenic in origin, but infection eg bilateral pneumonia
should be considered in the setting of fever and would justify antibiotic therapy.
Superadded low vascular resistance in the setting of possible sepsis.

Final Diagnosis
Extensive myocardial ischaemia or infarction as the primary cause of hypotension, but
intercurrent sepsis as an initiator/contributor to the deteriorated haemodynamic state.

Management Strategy
The LAP is high and the LV “full”. He may have improved cardiac output with a small initial fluid
bolus, but unlikely to be fluid responsive with a lot more fluid.
Inotropic therapy titrated to assessment of adequacy of cardiac output: Capillary refill time,
Lactate, HR, BP, pulse pressure, urine output, cardiac index (if measured) and repeat echo.
CO monitoring with a pulse contour-based monitoring device or pulmonary artery catheter (be
aware that each system has their own associated advantages and disadvantages and that the
clinician needs to accurately assimilate and interpret the results. There is no good evidence to
suggest that their insertion improves patient outcomes.)
Septic screen - Sputum and blood culture, atypical pneumonia serology
Empirical antibiotics for community acquired pneumonia
Cardiology review and consider anticoagulation, especially if the clinical situation is consistent
with acute myocardial ischaemia.

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