Morning Report

Diana GirnitaMD, PhD

94 yo White female admitted in the ER

CC: Shortness of breath

What would you like to know?

•Dyspnea initially with exertion, then at rest over a 24h period

•Cough with white mucus•Recently, admitted for 2 weeks at TCH •3 days after d/c presented back to TCH

with SOB

ROS• CONSTITUTIONAL: Subjective fevers, no chills. Weight

gain > 10 lbs over her baseline weight of 103 pounds. Weakness

• EYES: no photophobia or discharge • ENT: no sore throat or ear pain. Reduced hearing• CARDIOVASCULAR: knife type of CP for seconds, no

palpitations• GI: no abdominal pain, N/V/ some diarrhea for 2 days -

resolved. • MUSCULOSKELETAL: no back pain/ muscle pain • SKIN: No rash • NEUROLOGIC: No HA, focal weakness or sensory changes • ENDOCRINE: No polyuria or polydypsia • PSYCHIATRIC: no depression, suicidal ideation or

homicial ideation

PMH• HTN. Hyperlipidemia . CHF• Arthritis • Breast cancer s/p Left masectomy with

lymph node removal• Urinary Incontinence• GERD • Hearing loss• Asthma • Cataract • Anxiety

Meds•Amlodipine 10mg/ day•ASA 81 mg/day•Hydralazine 10mg Q8H•Lisinopril 20 mg BID•Metoprolol 25mg BID•Nitro 0.2mg/hr patch•Furosemide 40mg/day•Pantoprazole 40mg po•Lipitor 40mg/day•Ergocalcipherol Q7days

FH and Social

•FH not significant•Social: not a smoker, no EtOH, no ilicit

drugs, retired, former dancer

VS

At admission in the ER:•SaO2 at RA 87% •ABG 7.47/30/50/21.5;•started on 4L/min O2 on NC

•BP 107/58 | Pulse 83 | Temp(Src) 97.3 °F (36.3 °C) (Oral) | Resp 31 | SaO2 91% |

Physical exam• General: well developed, well nourished • HEENT: PERRLA, EOMI, throat non-edematous or

erythematous, mucous membranes moist • Neck: normal ROM, nontender, trachea midline,

lymph nodes non palpable , no JVD, no carotid bruit • CV: RRR, distant S1, S2, no m/r/g w/o PMI.• Resp: dullness about one third up, with diminished

BS bilaterally, without rales • Abd: soft, slightly distended, positive normoactive

BS, nontender • Ext: 2+ pulses, 1+ pitting edema • Skin: warm, dry, and intact, no rash • Neuro: alert and oriented x 3, CN II-XII grossly

intact, motor and sensory function intact with no focal deficits

Differential diagnosis

Pulmonary vs cardiac causes▫ Upper airway obstruction:

trauma, laryngeal edema, laryngospasm, aspiration of foreign body, epiglotitis, croup

▫ Lower airway obstruction: asthma, COPD, neoplasm

▫ Pulmonary infection: PNA, empyema, absscess, TB, bronchiectasis

▫ PE▫ Pulmonary HTN▫ PNTx▫ Pleural effusions▫ Interstitial lung dx: sarcoidosis,

collagen vascular disease, pulmonary fibrosis

▫ Pneumoconiosis: silicosis▫ mesothelioma

• MI• Valvular lesions• Arrythmias• CHF decompensation• Pericardial effusion/cardiac

tamponade • CMP• Ao dissection• CAD• Cardiac shunts

Other causes• Musculoskeletal: broken

ribs, severe kypho scoliosis, sternal compression, morbid obesity

• Gastrointestinal (large hiatal hernia)

• Neurologic disease: GBS, polio, botulism, spinal cord injury

• Thyreotoxicosis • Uremia, DKA, hepatic

coma

• Anemia –acute blood loss• Polycythemia • Diaphragmatic

compression caused by abdominal distension /ascitis

• Sepsis• Diaphragmatic paralysis• Anxiety

Labs

•CBC•BMP•Cardiac enzymes•D-dimers•Liver profile•BNP•LA

ECG 12/19/11 – did not differ from previous admission

Previous admission- Type A aortic aneurism with dissection and intramural hematoma 2 weeks ago•CC: substernal pain for about 2 days•Coded due to PEA• 2min CPR done, pulse regained •Complications of CPR: 2-6 broken ribs•D/c stable on medical management of

HTN to a SNF

Previous CT 12/02/2011• R 2-6th, and possibly the 7th rib fractures

• CT Chest:▫ Mildly increased size of the ascending thoracic aorta aneurysm

with type A dissection 5.6 x 5.1 cm (previously 5.2 x 4.8 cm on 11/28/2011).

▫ Increased size of ascending aorta intramural hematoma▫ Increased size of pericardial effusion with with component of

hemopericardium▫ Increased moderate pleural effusions with simple fluid increased

bilateral lower lobe passive atelectasis▫ Stable mild fusiform dilation of proximal descending thoracic aorta

measuring 2.8 cm

• CT Abdomen:

No abdominal aorta aneurysm or dissection

Previous ECHO 12/02/2011• LV: The cavity size was normal. Wall

thickness was normal. Systolic function was normal. The estimated EF-60 to 65%.

• Pericardium - moderate to large, echogenic circumferential pericardium with small echo-free visceral and parietal pericardial spaces, suggestive of possible effusive or hemorrhagic pericarditis.

• Pericardial tissue grossly thickened without significant intra-pericardial fluid.

What to order next?

CXRV/Q scan CTPA

CXR 12/19/11

•Significant reduction in bilateral effusions and lower lung airspace disease since previous exam

V/Q scan 12/19/11

•Intermediate probability pattern for pulmonary embolus

What is the next step?

ECHO CT chestLEs venous doppler

ECHO revealed cardiac tamponade• LV cavity size was normal. Wall thickness -normal. Systolic

function was normal. The estimated EF = 65%. Wall motion was normal; there were no regional wall motion abnormalities. Dopplerconsistent with abnormal LV relaxation (grade 1 diastolic dysfunction). Aortic valve:Trivial regurgitation

• Pericardium: A large free-flowing pericardial effusion was identified circumferential to the heart. The fluid exhibited afibrinous appearance.

• There was RV chamber collapse for less than 50% of the cardiac cycle.

• There was evidence for increased RV-LV interaction demonstrated by respirophasic changes in tricuspid velocities. Featureswere consistent with tamponade physiology.

LEs venous doppler 12/20/11

•acute, isolated, occlusive deep venous thrombosis involving the bilateral soleal veins in the mid calves.

•no evidence of superficial venous thrombosis in the bilateral lower extremities.

• no evidence of significant venous valvular incompetence in the deep or superficial veins of the bilateral lower extremities

Consults

•Cardiology•Thoracic surgery•Palliative care

Problem list

1.Hypoxic respiratory failure▫Cardiac tamponade 2/2 Ao dissection▫PE 2/2 LEs DVTs▫Rib fractures

2.AKI

3. Anemia. Thrombocitosis

4.Abnormals LFTs/ passive congestion liver

Plan

•IVC Filter•No pericardial drainage•US guided thoracocentesis (removed 600

ml blood tinged fluid on the L side)•IVF at 50ml/hr, then Lasix iv ---po•Xopenex Q6H•Metoprolol 25mg BID, stopped all other

hypertensive meds

Repeat CT chest after fluid removal•Type A aortic dissection with dilatation of

the ascending aorta to 5.6 cm, unchanged. Intramural hematoma is unchanged.

•Large complex pericardial effusion, increased from 12/10/2011.

• Moderate bilateral pleural effusions, worse on the right, similar to 2/10/2011

Aortic Dissection

Definition• tear in the aortic intima, blood passes into the aortic

media through the tear, separating the intima from the surrounding media and/or adventitia, and creating a false lumen

Common presenting group

▫>50 yo with HTN▫2/3 male▫Marfan’s syndrome▫Congenital heart disease▫Pregnancy

Clinical features▫>85% abrupt onset, severe pain in chest or b/w

scapula, described as “ripping or tearing”▫Pain in anterior chest –ascending aorta (70%)▫Back pain (less common) –descending aorta

(63%)▫If dissection into carotid classic neuro

symptoms▫40% with neurologic sequelae (ex. paraplegia)▫Most have sense of impending doom!

Classification

•Stanford Classification▫Type A -involves ascending aorta▫Type B –involves descending aorta

•DeBakey Classification▫Type I –ascending, arch & descending

aorta▫Type II –ascending only▫Type III –descending only

Physical Exam▫Usually normal heart and lung exam▫May have aortic insufficiency▫<20% with decreased radial, femoral or

carotid pulse▫HTN/ hypotension▫Tachycardia

Physical Exam▫Pericardial tamponade (muffled heart

tones, JVD, pulsus paradoxus)▫Hoarseness (compression of recurrent

laryngeal nerve)▫Horner’s Syndrome (compression of

superior cervical sympathetic ganglion)

•Acute type A aortic dissection was complicated by cardiac tamponade in 19% of patients

ELDERLY -presentation

•more likely to have atherosclerosis, prior aortic aneurysm,iatrogenic dissection, or intramural hematoma

•Less likely to have the abrupt onset of pain or any pulse deficit or a murmur of aortic regurgitation

•less likely to undergo surgery•had a higher mortality with either surgery

or medical therapy.

Diagnosis

•Thoracic Dissection▫90% have abnormal CXR

Widened mediastinum Abnormal aortic contour Pleural effusion Deviation of trachea, mainstem bronchi, or

esophagus Intimal calcium visable & distant from edge

(calcium sign)

CT 83-100% sensitive 87-100% specific CT with IV contrast Will not give anatomic details of arterial branches or aortic valve competence.

Modality of choice in unstable patient

Angiography

“Gold standard” Shows all anatomy and involvement 94% specific 88% sensitive

TEE

97-100% sensitive97-99% specificEsophageal dz contraindication

ED Treatment▫Treat hypertension

-blocker Esmolol 500g/kg IV bolus over 1 minute then

50-150 g/kg minute Metoprolol 5mg q2min x3 IV then 2-5mg/hr Propranolol 20mg IV then 40mg, 8-mg q10min

to 300mg total Calcium channel blocker if -blocker

contraindicated

Treatment ▫Vasodilator

Nitroprusside 0.3 g/kg/min IV▫Surgery

OR for ascending aortic dissection Descending aortic dissection worse surgical

risks –controversial for repair

Thank you!