Ultrasound for Critical Care Physicians: A Tempting Dilemma

Issam Marzouk MD

Lana Melendres MD

Michel Boivin MD

Division of Pulmonary, Critical Care and Sleep

Department of Medicine

University of New Mexico School of Medicine

MSC 10-5550

Albuquerque, NM 87131 USA

A 46 year old woman presented with progressive severe hypoxemia and a chronic appearing pulmonary embolus on chest CT angiogram to the intensive care unit. The patient was hemodynamically stable, but had an oxygen saturation of 86% on a high-flow 100% oxygen mask. The patient had been previously investigated for interstitial lung disease over the past 2 year, this was felt to be due to non-specific interstitial pneumonitis. Her echocardiogram findings are as presented below (Figures 1 and 2).

Figure 1. Parasternal long axis view. Upper panel: static image. Lower panel: video.

 

Figure 2. Apical four chamber view. Upper panel: static image. Lower panel: video

The patient had refractory hypoxemia despite trials of high flow oxygen and non-invasive positive pressure ventilation. She had mild symptoms at rest but experienced severe activity intolerance secondary to exertional dyspnea. Vitals including blood pressure remained stable and normal during admission and the patient had a pulsus paradoxus measurement of < 10 mmHg. She had previously had an echocardiogram 6 months before that revealed significant pulmonary hypertension.

What would be the most appropriate next step regarding management of her echocardiogram findings? (click on the correct answer to move to the next panel)

1. Diagnostic pericardiocentesis
2. Urgent therapeutic pericardiocentesis
3. Avoid pericardiocentesis at this time
4. Urgent thrombolysis with tissue plasminogen activator

Reference as: Marzouk I, Melendres L, Boivin M. Ultrasound for critical care physicians: a tempting dilemma. Southwest J Pulm Crit Care. 2014;9(3):193-6. doi: http://dx.doi.org/10.13175/swjpcc128-14 PDF