What’s Your Diagnosis? Advances in Cardiac Resuscitation in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last month’s case on Managing Acute Cardiac Valvular Emergencies in the Emergency Department correct.

Case Presentation: Advances in Cardiac Resuscitation in the Emergency Department 

An 82-year-old woman arrives to the ED by EMS with a complaint of dyspnea…  

• The EMS team informs you that the patient’s family called 911 because she has been increasingly tired and short of breath. 
• Her family states that she has a “weak heart,” and report a history of hypertension that is being treated with multiple agents. 
• In the ED she is somnolent, with cool and mottled extremities. Her heart rate is 45 beats/min; blood pressure, 114/71 mm Hg; and SpO2, 88%. Her ECG shows a junctional bradycardia with no ischemic changes. She has crackles diffusely through her lung fields with decreased air entry bilaterally on auscultation. 
• What is most concerning about this patient‘s presentation, and what is the most appropriate next step in her management? 

Case Conclusion

You were concerned about cardiogenic shock with pulmonary edema, so you performed a point-of-care echocardiogram that showed depressed left ventricular function. Imaging showed >3 B-lines in multiple lung areas. You placed her on bilevel positive airway pressure to support her breathing, and decided to start an inotrope. Her oxygenation improved to 96%, but she was still somnolent, with cool and under-perfused extremities. You were concerned that her rhythm and rate were the cause of her low cardiac output. You successfully placed a transvenous pacing wire and started cardiac pacing at 80 beats/min. Her skin color improved, and her lactate decreased. She was transferred to the cardiac ICU for further management. 

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Last Updated on January 26, 2023