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History of Present Illness:

A 62-year-old male presents is brought to the ED for cardiac arrest.  He collapsed on the street.  No other history is available.  The initial rhythm was a slow, wide PEA.

Vital Signs & Physical Exam:

The face is plethoric.  Rapid bedside US is done.  During CPR the abdomen is checked and shows no intra-abdominal free fluid.  During the first rhythm check while hands are off the chest the heart is checked and shows no cardiac motion, but there is a small to medium sized gray-colored pericardial effusion.

PEA Differential Diagnosis:

  • High: K, acid, tox
  • Low: oxygen, BP, glucose, temperature, K
  • Clot: MI, PE
  • Collection: PTX, tamponade

Imaging:

  • The echo image was not saved
  • A chest x-ray is shown below.

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA

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ANSWERS:

  1. What does the case image show?  The image shows a very wide mediastinum.
  2. What should you do next?  If the patient has not been down long you could consider pericardiocentesis, but at this stage the chance of saving him are essentially zero.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Tarascon Emergency Department Quick Reference Guide 

CLICK HERE TO LEAR MORE ABOUT THIS BOOK

CASE CONCLUSION: Autopsy showed a type A aortic dissection with rupture into the pericardium

CASE LESSONS:

  1. This patient was beyond saving but it is important to know that tamponade from aortic dissection is ACUTE and BLOODY and therefore presents with a small to medium effusion, NOT a large one, and the color on ultrasound will be gray, NOT black.
  2. It’s also useful to know that acute tamponade from dissection may cause upper body plethora, where the chest and face look a bit purple.  I have seen this before.
  3. Identifying these findings early could help you save a patient who is critical, but still alive
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