A 67-year-old man with hypertension and a history of smoking complains of days of nausea, chest pain, and shortness of breath.  He is being evaluated at triage when he collapses to the ground.  He is brought to the resuscitation bay, where he is weak and diaphoretic, but alert.

At triage, his vital signs are: HR 138 BP 72/40 RR 28 SpO2 96% RA

He has clear breath sounds with low tidal volume and muffled heart sounds.  Primary body check shows no evidence of trauma, source of infection, or toxidrome.  While you are gathering information, getting help to the bedside, and obtaining intravenous access, you place an ultrasound probe on his chest.  He has a moderate pericardial effusion, IVC dilation, and aortic root dilation.

Based on the information available in your brief exam and goal-directed echocardiography, which is the MOST likely cause of his shock?

    A.    Pulmonary Embolism
    B.    Aortic dissection
    C.    Sepsis
    D.    Myocardial infarction

In the meantime, a quote –

The two fulcra of medicine are reason and observation.  Observation is the clue to guide the physician in his thinking.

Introduction to De Praxi Medica

– Giorgio Baglivi (1669-1701)
Professor of Anatomy at Sapienza, Papal University, Rome


Chris link
03/25/2013 8:01pm

I'll lock in B.
The presence of chest pain, dilated aortic root and pericardial effusion (now with features of tamponade) suggest aortic dissection, which has back-dissected into the pericardium.
Risk factors; hypertension.

Do I dare take him to CT to confirm the diagnosis ? That's a tricky one.

03/27/2013 11:53am

Great comment, clear logic, and important practical concerns


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