USMLE Critical care practice question

Question

I 65-year-old female is admitted to the ICU with hypotension and a Swan-Ganz catheter is placed for management. She has a history of lung cancer which was treated. V/S: P 110 BP 89/75 T 98.9 R 20

PA: CI 1.2, PCWP 23, CVP 23, PAP 38/22, RV 39/23

physical exam is limited but demonstrates distended external jugular veins. Suddenly weak pulses disappear and heart monitor shows sinus tachycardia. Besides CPR, what should be done next?

A: Stat echo

B: IV epinephrine

C: Fluid bolus

D. Pericardiocentesis

Answer 1

The key here is end diastolic equalization number on the right side match the diastolic pressures that are measured,

Thus pericardial tamponade is occurring.

As there is arrest a subxiphoid approach with a spinal needle which is under chronic aspiration tension after entry in to the skin. once fluid or blood is obtained, stop advancing the needle and continue aspiration. One may say place egg lead on it because if the trace shows rhythm your touching the heart.

in acute setting 100ml is enough, in chronic setting over a liter may be present. Thus one should use at least a 60ml syringe.

Answer 2

Typical USMLE style question. In this case there are a few different ways to recognize the diagnoses. Also important information will be present on other questions. diagnosis: pericardial tamponade.

multiple clues to the diagnosis. Don’t have full Beck’s triad Of hypotension, elevated JVP, and muffled heart sounds but we’re close. Also note narrow pulse pressure. Diagnostically note equalization of left atrial, right atrial, pulmonary and ventricular diastolic pressures. Note low cardiac output. This present is cardiogenic shock but would correctly be identified as obstructive shock. Note lung cancer is significant clue. Pathology: as fluid continues to build up between the pericardium and heart The chambers fill with less and less blood lowering continually the cardiac output. Hypertension and tachycardia continue to worsen . If the effusion occurs rapidly a small amount of blood can cause Tamponade if it accumulates slowly a very large effusion can be tolerated. The treatment for this is emergent pericardiocentesis. If not treated this will result in PEA and death