January 2020 Winner
"Hypotensive Heartache"
Bill Fox, MD at BSWH - Dallas
HPI: 68M BIBEMS from LTAC for hypotension and respiratory distress. The patient was initially sent to LTAC after CABG complicated by respiratory failure. The patient is nonverbal, but EMS reports the patient is requiring increased ventilator support and has progressively decreased blood pressure. The patient is normally not on a ventilator but has been on a vent for 2 days due to respiratory distress. No other history is available.
VS: BP: 117/51, HR: 103, Temp: 101.7 °F (38.7 °C), RR: 23, Height: 5' 11" (180.3 cm), Weight: 198 lb 6.6 oz (90 kg), BMI: 27.7, SaO2:88 %
Physician Exam:
Const: alert, awake
HEENT: NC/AT, PERRLA, EOMI, Periorbital areas with no swelling or redness, neck supple, trachea midline
CV: RRR, Intact distal pulses, no rub or gallop, no JVD, normal PVI
Chest: R chest permacath in place
Resp: Tachypnea noted. He is in respiratory distress. No wheezes, no rhonchi, no rales, but coarse breath sounds
Abd: Soft non distended, non tender, no guarding, well healing drain sites
MSK: normal range of motion, no cyanosis
Neuro: alert and follows commands
EKG: Diffuse STE V3-V6, PR prolonged at 216, Sinus tachycardia at 122
ED Course:
• Patient with intermittently declining O2 saturations
• No improvement with increased ventilator support or pronation/recruitment maneuvers
• Bronchoscopy did not revel mucous plugs
• Pressor requirements continued to increase
Labs
• WBC 4.9 Hemoglobin 10.4 Hematocrit 35.1 Platelets 412
• Na 128 K 5.0 Cl 93 CO2 22 Ca 8.2 BUN 76 Cr 7.76 Glucose 76
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