# Bizarre Cardiac Case



## thegreypilgrim (Mar 9, 2011)

Please forgive the horrendous misspelling of "bizarre" in the title. I only recognized it after submitting and can no longer edit! 

Perhaps this is an argument for prehospital use of ultrasonography. This scenario is not something I encountered, but has been adapted from a published case report - the citation of which I have included below but no cheating! Try to figure this out without accessing the original article.


You are called to the scene of a private residence in a predominately middle-class neighborhood. The home appears well-maintained, several cars are parked in the driveway, and you are greeted at the door by an elderly man who directs you to the patient which is his wife.

*History of Present Illness.* You observe a 61 year old female complaining of chest pain with associated nausea and dyspnea. Chest pain was the initial symptom which developed suddenly, is described as a "pressure" type pain, radiating to the left shoulder. The pain was non-provoked and displays no apparent palliative features. It is not exacerbated by inspiration or palpation, and onset approximately 45 minutes ago.

*PMH.* Patient reports no medical history

*Allergies.* No known allergies

*Medications.* Patient denies taking any medications

*Social History.* Patient reports 40 pack/year smoking history

*Family History.* Unavailable

*Physical Exam*
Constitutional: Patient is well-developed, well-nourished, but is obese. Appears in severe distress
Vitals: BP 70/P, Pulse 124, RR 24, SpO2 100%
Neuro: Patient is Awake, Alert, and Oriented. Cooperative, but anxious and restless. CNII-XII grossly intact.
HEENT: Head is normocephalic and atraumatic with no visible lesions or masses. Pupils PERRLA. Normal facial symmetry. 
Neck: No masses, trachea midline, no tenderness, no apparent JVD
Chest: Normal chest wall excursion, heart sounds equivocal (difficult to auscultate), mild crackles in right axial and posterior regions
Abdomen: Soft, non-tender. No pain. No masses. No HSM
Extremities: Patient moves all extremities. No pain. No masses. Weak distal pulses
Pelvis: No pain or trauma. No abnormal bleeding or discharge.
Skin: Diaphoretic and ashen skin. Normal turgor. No visible dependent edema. No clubbing of nails.

Initial 12-lead shows ST-elevation in leads II, III, and aVF (sorry, due to copyright issues I'm not going to post the image).

However, after intervention the patient's pain completely resolves and the ST segments return to baseline. Not long after the patient experiences recurrent chest pain with ECG changes showing ST-elevation in I, II, III, aVF, and V6 with an underlying 2nd degree type II AV block which quickly degenerated into unsustained ventricular tachycardia followed by PEA.

ROSC was obtained in the ED, the patient was admitted to the ICU and ultimately died 7 days later.

What is your diagnostic impression of this patient, and how would you have managed her if you were on this call?


Here is a link to the original article which has the ultimate diagnosis in the title. So please give it your best shot before looking, and don't spoil it for everyone!


----------



## abckidsmom (Mar 9, 2011)

What intervention do you mean?  Bolus?  Pressors?  


With the only real abnormality on the whole exam (aside from her hemodynamic instability) being the muffled heart sounds, is there some component of pericarditis or tamponade in play here?


----------



## thegreypilgrim (Mar 9, 2011)

abckidsmom said:


> What intervention do you mean?  Bolus?  Pressors?


 It's not listed.  




> With the only real abnormality on the whole exam (aside from her hemodynamic instability) being the muffled heart sounds, is there some component of pericarditis or tamponade in play here?


Is that the only abnormality?


----------



## 8jimi8 (Mar 10, 2011)

abckidsmom said:


> What intervention do you mean?  Bolus?  Pressors?
> 
> 
> With the only real abnormality on the whole exam (aside from her hemodynamic instability) being the muffled heart sounds, is there some component of pericarditis or tamponade in play here?



Doesn't pericarditis present c STE in all leads?


----------



## EMTinNEPA (Mar 10, 2011)

Jimi, you are correct that pericarditis typically presents with diffuse, global, non-diagnostic ST segment elevation.  Typically, the patient will also be febrile.  This presentation suggests pericardial tamponade, although one would suspect jugular venous distension.  The other two components of Beck's Triad (hypotension and muffled heart sounds) are present.  With the rales, it sounds like the patient may be going into acute CHF secondary to impaired cardiac output.  This patient is almost certainly in cardiogenic shock.  My treatment would include pressors, high flow O2, and rapid transport.  I highly suspect that the patient is not being truthful about her history and meds, especially at the age of 61.


----------

