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- W4311593891 abstract "Introduction: Obstructive shock is an obstruction of blood flow in the central vessels of the systemic or pulmonary circulation causing hemodynamic compromise. Here, we describe the unique challenge of managing a patient in shock with simultaneous hemorrhagic pericardial effusion and bilateral mainstem pulmonary emboli (PE) in setting of disseminated intravascular coagulation (DIC). Description: A 63-year-old female former smoker with recent deep venous thrombosis presented with 4 days of weakness, shortness of breath, and inability to tolerate oral intake, including apixaban. She was tachycardic, tachypneic and hypotensive. She was fluid resuscitated and BP improved from 83/43mmHg to 104/56mmHg. She later became hypoxic, requiring 6L oxygen by nasal cannula. Labs showed platelets 20k/mm3, D-dimer >35.2mg/L, Troponin T 0.56ng/mL and NT-proBNP 1864pg/mL. Bedside echocardiogram showed a large pericardial effusion. Chest CT angiography showed an acute PE involving the bilateral main pulmonary arteries and a new 4.0 cm spiculated right lung mass. A heparin drip was started and her oxygenation improved, however she became more hypotensive, requiring further fluid resuscitation. Repeat labs showed lactate 4.8mmol/L, platelets 4k/mm3, INR 3.6, aPTT 47s, haptoglobin < 10mg/dL and fibrinogen 50mg/dL, demonstrating DIC. Follow up echocardiogram showed tamponade physiology. The patient was transfused with fresh frozen plasma and platelets, eventually requiring vasopressor support. She was taken for CT-guided pericardiostomy with resolution of her shock. The pericardial fluid was grossly bloody, and the pathology showed adenocarcinoma. Discussion: This patient presented a diagnostic dilemma in ascertaining the primary cause of her obstructive shock. Echocardiographic features of obstructive shock due to RV failure secondary to central pulmonary embolism may not be evident in the setting of concurrent pericardial effusion. The clinical findings of a small right ventricle, worsening hypotension after heparinization as well as improvement in hemodynamics after pericardiostomy confirms that cardiac tamponade was the primary etiology for her obstructive shock. Findings of RV dilatation and hypokinesis after near complete drainage of pericardial effusion suggests that the PE was causing hemodynamic compromise as well." @default.
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- W4311593891 date "2022-12-15" @default.
- W4311593891 modified "2023-10-01" @default.
- W4311593891 title "1256: DIFFERENTIATING OBSTRUCTIVE SHOCK: A CASE OF SIMULTANEOUS CARDIAC TAMPONADE AND PULMONARY EMBOLISM" @default.
- W4311593891 doi "https://doi.org/10.1097/01.ccm.0000910760.52798.0f" @default.
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