A 58 year old man is brought in by ambulance moribund with barely palpable pulse and a sinus tachycardia.
(b) His condition improves with therapy. When his wife arrives she tells of his recent hip replacement complications by a bleeding duodenal ulcer. What are the likely diagnoses?
How will you establish the definite diagnosis and why?
(b) This provides some help.but is not definitive. Possible causes still include pulmonary embolus. hypovolaemia from bleeding DU. myocardial infarction etc. A progression from simple/quick investigations to more complex but specific/diagnostic investigations should be outlined. There should have beeo a sense of appropriate priorities.
If there are signs of GIT bleed with hypovolaemia, then fluid resuscitation, NG tube insertion, endoscopy, FBC and coag screen will be indicated along with anti-ulcer therapy and perhaps surgery.
If there are signs of acute myocardial infarction. in the setting of recent DU, angiogram and angioplasty would be a preferable course perhaps after urgent echo.
If there are signs of massive pulmonary embolus (right heart failure), and initial tests are supportive (right heart strain on ECG, oligaemic lung on CXR, distended RV on echo), a spiral CT would be indicated with commencement of IV heparin
This part of this multi-part question offers some explanation as why the patient is "moribund". In essence, it narrows the differentials generated by the "4 Hs and 4 Ts" approach, which one can use to systematically organise one's diagnostic approach to this peri-arrest scenario in the first part of this question.
Thus, one would organise the following investigations:
The following specific management could be commenced while awaiting results:
Seeing as both bleeding and thrombosis are a part of the differentials, anticoagulation/thrombolysis should be thought about but left until investigations reveal more about the cause of this shock state.