Case 6 - Cardiogenic Shock - 2
Indication:
(i) Shock Differentiation: The patient was evidently in shock. Given the progressive shortness of breath on exertion and presyncope on a background of aortic valve stenosis that likely progressed, cardiogenic shock was considered. The counter argument would be the clear lung fields on auscultation, lack of clinical evidence of cardiogenic pulmonary edema, would make it less likely.
However, of note, in the Shock Trial, 30% of cardiogenic shocked patients were "cold" and "dry". Hence, PoCUS was deployed to assess the cardiac function, specifically, the LVEF.
Image Acquisition:
Given the adequate JVP visualization on physical exam, the IVC was not imaged.
The subcostal view was pursued first at the patient was sitting up at the time which would improve the likelihood of success imaging as the heart displaces caudally. The subcostal short view was pursued due to the poor parasternal views. The LV short view would be very informative regarding the LV function. The A4/5 were pursued due to the poor parasternal windows in order to better view the LV, AV, and MV.
(i) Shock Differentiation: The patient was evidently in shock. Given the progressive shortness of breath on exertion and presyncope on a background of aortic valve stenosis that likely progressed, cardiogenic shock was considered. The counter argument would be the clear lung fields on auscultation, lack of clinical evidence of cardiogenic pulmonary edema, would make it less likely.
However, of note, in the Shock Trial, 30% of cardiogenic shocked patients were "cold" and "dry". Hence, PoCUS was deployed to assess the cardiac function, specifically, the LVEF.
Image Acquisition:
Given the adequate JVP visualization on physical exam, the IVC was not imaged.
The subcostal view was pursued first at the patient was sitting up at the time which would improve the likelihood of success imaging as the heart displaces caudally. The subcostal short view was pursued due to the poor parasternal views. The LV short view would be very informative regarding the LV function. The A4/5 were pursued due to the poor parasternal windows in order to better view the LV, AV, and MV.
Interpretation:
Global severe LV hypokinesis was noted which markedly deteriorated from previous. Both the aortic and mitral valves were not opening which may suggest both stenosis have progressed to the severe stage. Nevertheless, without formal measures such valvular conclusions cannot be made.
Clinical Synthesis:
The patient was in cardiogenic shock, dry and cold subtype, likely due to stenotic valvulopathies. Cardiology consultation was made. Dobutamine and norepinephrine were both commenced though patient was rendered palliative shortly after admission.
Global severe LV hypokinesis was noted which markedly deteriorated from previous. Both the aortic and mitral valves were not opening which may suggest both stenosis have progressed to the severe stage. Nevertheless, without formal measures such valvular conclusions cannot be made.
Clinical Synthesis:
The patient was in cardiogenic shock, dry and cold subtype, likely due to stenotic valvulopathies. Cardiology consultation was made. Dobutamine and norepinephrine were both commenced though patient was rendered palliative shortly after admission.