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BACKGROUND
A 40-year-old woman arrives at the emergency department
with a markedly panicked appearance, screaming, "I can't
breathe!" She is anxiously flailing her arms and appears
tachypneic and pale. Six nurses are needed to obtain her
vital signs and to place an intravenous (IV) line. The
patient's heart rate is 120 beats per minute (bpm) with
a blood pressure of 200/88 mm Hg, a respiratory rate of
50 breaths per minute, and oxygen saturation of 79% with
the patient breathing room air. She is unable to
cooperate with history taking and physical examination,
and she repeatedly removes her oxygen mask and
monitoring equipment. She is intubated on an emergency
basis by using rapid-sequence induction.
After the patient is adequately sedated, physical
examination is possible. The ventilator is set on
assist-control mode at a rate of 16 bpm, tidal volume of
600 mL, positive end-expiratory pressure (PEEP) of 5 cm
H2O, and a fraction of inspired oxygen (FiO2)
of 100%. Her vital signs include a rectal temperature of
37.1°C with a heart rate of 110 bpm, ventilator-assisted
respiratory rate of 16 breaths per minute, blood
pressure of 183/100 mm Hg, and O2 saturation
of 100%. Her pupils are equal, round, and reactive to
light. She has no jugular venous distension or tracheal
shift. Her heart rate is a regular rhythm with no
appreciable murmurs, rubs, or gallops. She has coarse
breath sounds with bibasilar rales. Abdominal
examination reveals linea nigra, and moderate distension
is noted, but palpation yields softness without any
masses. She has no lower-extremity edema or rashes.
The patient's husband arrives and provides additional
history. They had a baby by means of normal spontaneous
vaginal delivery 2 months ago with no complications.
Three days ago, the patient began having shortness of
breath, which was worst at night and when she was lying
flat or exerting herself. She has been using an
over-the-counter epinephrine inhaler (0.22 mg, Primatene
Mist), with no improvement. She has no notable medical
history of asthma, chronic obstructive pulmonary disease
(COPD), or other respiratory problems. He denies any
knowledge of drug or alcohol use.
An ECG
shows sinus tachycardia with frequent premature
ventricular contractions (PVCs). The patient has no
ST-segment or T-wave changes and no S1Q3T3 pattern.
A portable postintubation chest radiograph is obtained
(see Image 1). Bedside abdominal and cardiac
ultrasonographies are performed in the emergency
department. The sonogram of her abdomen shows no free
fluid and a nongravid uterus. Images 2-4 are her cardiac
sonograms.
What is the diagnosis and
treatment?
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Hint
The patient had no symptoms before she became pregnant. |
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Authors:
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Adam Landman, MD, MS, MIS,
UCLA/Olive View-UCLA Emergency Medicine
Residency Program,
Los Angeles, Calif
Gelareh Zargaraff, MD,
UCLA/Olive View-UCLA Emergency Medicine Residency Program,
Los
Angeles, Calif
Timothy Jang, MD,
Attending Physician,
Department of Emergency Medicine,
Director of Emergency Ultrasound,
Olive View -UCLA Medical Center,
Assistant Professor of Medicine,
David Geffen School of Medicine at UCLA
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eMedicine Editor:
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Erik D. Schraga, MD,
Department of Emergency Medicine,
Kaiser
Permanente,
Santa Clara Medical Center, Calif
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