Thread by @SkylerLentz

Important lessons 📜 from ICU case:

🚨Not everything is septic shock
🚨A limited echo has limitations

Older patient in shock on 3 vasopressors, who initially presented with dyspnea and a CXR like 👇

What the diagnosis?

#FOAMed #FOAMcc

Image credit: ahajournals.org/doi/10.1161/CI…

Presented to the ED with acute onset dyspnea, new O2 requirement 6 L NC, minimal PMH

BP 95/70, HR ~ 100, afebrile

Hypoxemia worsened during ED stay requiring intubation

Now hypotensive

CT obtained with unilateral right sided pulm infiltrates, small pleural effusions, no PE

Labs 🧪

WBC 20k

Troponin mild elevation

Lactic acid 5.0

Cr mild elevation

U/A with > 50 WBC

Antibiotics, 2 L IVF given and admitted to ICU

🛌Arrival to ICU

B: 50% FiO2 PEEP 10

C: BP 80/60 HR 120s on
Norepi 40 mcg/min
Vasopressin .03 u/min
Epi 5 mcg/min

Distal extremities cool, oliguric, systolic heart murmur heard over vent (old per notes)

Middle of night POCUS 🫀

RV mildly dilated but systolic function looks ok
IVC 2.5 cm minimal variation
LVEF is normal
AS suspected on visual assessment

Comprehensive echo ordered for better valve assessment in AM

Must be pneumonia and sepsis, right?

Time, antibiotics, source control...

Echo next morning gives the diagnosis:

Severe AS
+
Acute chordae tendineae rupture with severe MR

📜Lessons:

✔️Not everything is septic shock
✅Normal LV/RV function does NOT rule cardiogenic cause of shock-low cardiac output from MR+AS despite normal EF in this case
☑️Severe MR can cause unilateral pulmonary edema
✔️Narrow pulse pressure (BP 80/60) hints at cardiac cause