What's the Diagnosis? By Dr. Katie Selman

Wed, 11/07/2018 - 7:00am
Author: 
Katie Selman, MD
Editor: 
Jillian Smith MD

A 67 yo M w/ a PMHx of IVDU presents to the ED w/ chest pain and fever of 101.5. His initial HR is 135. A CXR is obtained and he is started on broad spectrum antibiotics. An hour later, he begins complaining of worsening shortness of breath, and is found to be tachypneic and hypoxic, w/ a RR of 40 and SpO2 of 85 %. A repeat CXR is obtained (shown at R below, initial CXR on L).  What's the diagnosis? (scroll down for answer)

 

 

Answer:  Flash pulmonary edema

  • May be cardiogenic (acute decompensated heart failure) vs. non-cardiogenic (ex: ARDS) in origin
  • Risk factors: history of CHF or valvular disease, history of ESRD, recent MI, hypertensive emergency, blunt thoracic trauma, iatrogenic fluid administration
  • Diagnosis
    • CXR: b/l interstitial infiltrates
    • Ultrasound: numerous B lines bilaterally
    • BNP often lags if fluid overload occurs abruptly
    • PaO2/FiO2 ratio <300 diagnostic of ARDS
  • Treatment
    • Positive pressure ventilation: CPAP vs BiPAP, high flow nasal cannula or intubation
    • Diuresis
    • Nitrates
    • 6-8mL/kg tidal volume in ventilated patients
    • Treatment of underlying cause
  • In this patient w/ history of IVDU, the top differential diagnoses were ARDS due to sepsis vs. acute valvular disease due to endocarditis
  • Patient was ultimately found to have severe mitral regurgitation on echo with suspected papillary muscle rupture

 

 

 References:

 

Alley, William D., and Simon A. Mahler.. "Valvular Emergencies." Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016

 

Braithwaite, Sabina A., and Debra Perina. “Dyspnea.” Rosen’s Emergency Medicine: Concepts and Clinical Practice, 2nd ed., Elsevier Saunders, 2018, pp. 195-203. 

 

Sarko, John, and J. Stephan Stapczynski.. "Respiratory Distress." Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016

 

Seigel, Todd. “Mechanical Ventilation and Noninvasive Ventilatory Support.” Rosen's Emergency Medicine: Concepts and Clinical Practice, 2nd ed., Elsevier Saunders, 2018, pp. 25–33.