I wonder could I pick the collective brains of this list with a recent case?
58 year old woman calls an ambulance for acute dyspnoea at 4am. On arrival
of ambulance she is tachypnoeic 40/min, cyanotic with SpO2 60% on room
air. Minutes after ambulance arrival she collapses with respiratory arrest and
possible transient PEA.
On arrival at ED she is GCS 5/15 tolerating an OPA with agonal resps. Pulse
50bpm, sinus rhythm, BP 194/80mmHg. SpO2 89% with assisted ventilations -
very little air movement bilaterally. Temp 34.4.
She undergoes RSI with propofol and sux. Very tight lungs immediately post
intubation but responded well to salbutamol via ETT.
Initial ABG is Ph: 6.77, PCO2: 15.4, PO2 47.8, Base Xs: -19.3, HCO3: 10.6,
Lactate: 12, Blood Sugar: 19.2.
Portable CXR is clear. Clinically, the olnly finding is MR. Myocardium clearly
very irritable, multiple ectopics and runs of tachycardia and bradycardia.
She is treated as a DKA with insulin, fluids and NaHCO3.
CT Brain shows no bleed or infarct. D-dimers are raised at 3036 ng/ml (normal
0-200). CTPA shows no PE.
FBC, UEC, LFTs, TNI are all near normal.
ABG normalised within 2 hours of intubation. She did not require further
bronchodilators. No evidence of pulmonary oedema. Blood sugars stabilised
without further insulin.
ECHO reveals severe MR and some LVH. TNI has risen to 0.06. She has no
evidence of infection and was extubated the next day. Urine and blood
toxicology are negative. The patient denies any ingestion. No preceeding
symptoms reported.
She had an MI 10 years ago and takes Ramipril, Betaloc and Aspirin.
She is now well but d-dimers have risen to 7000.
Cardiology feel this is a NSTEMI with Mitral Regurgitation as a consequence.
Medics are unsure.
I wonder can anyone reconcile the massively elevated d-dimers with a
negative CTPA and the original ABG which improved rapidly following
ventilation? I have not seen the scan myself, but I imagine an embolus large
enough to cause this degree of compromise would not be missed?
I do not have the final answer yet!
Thanks,
David Menzies,
SpR Emergency Medcine,
Dublin
|