A Diagnostic Dilemma saved by sound

Transcription

1 A Diagnostic Dilemma saved by sound Dr Syam Ravindranath MBBS DNB, Dr Ash Mukherjee FCEM FACEM We p r e s e n t a d i a g n o s t i c a l l y c h a l l e n g i n g s c e n a r i o in a 59 y e a r old f i t m a n w h o p r e s e n t e d to o u r e m e r g e n c y d e p a r t m e n t c r i t i c a l l y u n w e l l. D i a g n o s i s w a s u n r a v e l e d by EP p e r f o r m e d point of c a r e t r a n s t h o r a c i c E C H O

2 Case description History 3 week history of feeling unwell, productive cough, SOB Commenced on oral antibiotics by GP Presented to our triage with lightheadedness, chest tightness and nausea PMH: Fit and healthy, non smoker, not diabetic and normotensive Brick layer- worked preceding 48 hours Physical examination Alert, pale, diaphoretic and moderate respiratory distress HR 96/mt BP 70 mm Hg palpable SpO 2 93% RA Hypothermic with cold peripheries Systemic survey CVS: JVPNE, Dual HS Chest: Bilateral crepitation, no wheeze Abdomen: Soft, nil organomegaly No evidence of DVT

3 ECG SHOWING ST ELEVATION V5,V6 CXR SHOWING UNILATERAL INFILTRATE ABG ON ARRIVAL Scenario: Critically ill shocked patient, clinical presentation suggestive of SEPTIC SHOCK Differential diagnosis 1. Distributive - Septic shock 2. Cardiogenic -Secondary to myocardial infarction 3. Obstructive - Massive PE or Cardiac tamponade Full blood count What do we do? Peripheral hospital without cardiology cover but level 3 ICU. What else can we do to get more information? Point of care ultrasound!

4 Figure1,2,3: Apical four chamber view of EP performed ECHO showing echogenic mass in the left ventricle (fig 1) with absent tip of papillary muscle (fig 2) and associated mitral regurgitation (fig 3) and left atrial dilatation ECHO FINDINGS Nil effusion, No RV strain Poor contractility of LV LAD distribution Severe Mitral regurgitation? Papillary muscle rupture/mitral valve vegetation LABS Raised inflammatory makers Acute renal impairment Deranged liver functions Troponin I of 69 Management Antiplatelets, ionotropes, antibiotics RSI transfer to tertiary center Angiogram: TVD CABG x 4 + MVR- Anterolateral papillary muscle rupture Multiple post op complications including cardiac tamponade, was on ECMO RIP 7 th post op day

5 Background Papillary muscle rupture Papillary muscle rupture is a rare complication of MI (Incidence 1-5%) 1-7 days post MI Indicator of bad prognosis High index of clinical suspicion in patients with ACS presenting in cardiogenic shock and APO Complete rupture of results in ischemic mitral regurgitation hemodynamic deterioration, cardiogenic shock, pulmonary edema and even cardiac arrest Incomplete rupture lesser degree of infarction and less hemodynamic instability Apical four chamber view : Ruptured papillary muscle seen as mobile mass of echoes in the left ventricle Absent tip of papillary muscle Mitral valve prolapse or regurgitation Suggest urgent bedside ECHO due to extremely high mortality Therapy is aimed at hemodynamic stability followed by valve repair or replacement

6 Mechanical complications of myocardial infarction Fatality as a result of MI usually from fatal arrhythmias and rarely by mechanical complications like papillary muscle rupture Anterior papillary muscle involvement in this case makes it very rare as posterior rupture is more common due to dual supply from LAD and LCX Routine investigations (ECG and cardiac enzymes) cannot detect mechanical complications of MI Suggest bed side ECHO(sensitivity of 65-85%) in critically ill patients Absence of cardiovascular risk factors and atypical presentation brought the diagnostic dilemma here with three likely possibilities of Sepsis, Infective endocarditis and ischemic papillary muscle rupture Post infarct early LV remodelling, contribution of inflammation and reperfusion injury by neutrophils Early infarct expansion and wall thinning and dilatation results in PMR and MR

7 Cardiac ultrasound in ED Clinical applications Hypotensive patient Early goal directed therapy with resuscitative ultrasound by assessing the pathology and physiology associated with shock Perera P et al in 2010 proposed 3 step approach of assessing pump, tank and pipe by RUSH exam Coronary artery disease Our case report highlights the need of ECHO in clinical suspicion of mechanical complications in MI Detecting RWMA by echo has high sensitivity of >90% and high negative predictive value >95% Pulmonary Embolism Excellent tool in triaging unstable cases which needs thrombolysis Studies by Ceylon et al and Kasper et revealed that ECHO findings of RV strain is associated with increase risk of death and occur in 27-55% of cases of PE Chest trauma A retrospective study by Plummer et al on use of EP performed ECHO in penetrating cardiac injury revealed less time to diagnosis and100% survival rate on ECHO group when compared to 57.1% in non ECHO group

8 Summary The initial clinical picture was that of Sepsis from pneumonia. Point of care echo alerted us to the alternate likely diagnosis. The immediate treatment strategy for the two conditions are different and PoC echo guided us appropriately. Working in a hospital with no cardiology or cardiothoracic cover, the decision to transfer the patient out of hospital rather than our ICU was expedited by the point of care ECHO. If PoC echo is not used early in such clinical scenarios, this clinical condition often ends up as a post-mortem diagnosis.