A 50 year old man was admitted with severe dyspnoea and hypotension.
Clinical examination revealed a tachypnoeic patient with a HR of 130/min, SR and a blood pressure of 90/60 mm Hg. On CVS examination, the JVP was raised, and a cardiac murmur was audible although because of the tachycardia, it could not be timed with certainty. Hemodynamic monitoring revealed the following:
CVP 14 mmHg,
Pulmonary artery 48/24 mmHg,
PAOP 22 mmHg.
List 3 likely causes for the above clinical and hemodynamic presentation.
1. Left ventricular failure/cardiogenic shock
2. Mitral regurgitation
3. Acute aortic incompetence
What would give you hypotension, tachycardia and a murmur? What could compel the Australian College of Intensive Care Medicine to use the American spelling of "haemodynamic"?
The abnormalities are:
With the raised PAWP and CVP, one starts thinking about cardiac causes. Certainly such a presentation might result from the sudden failure of the aortic or mitral valves (with ensuing pulmonary oedema). With a major pulmonary embolus, the PAWP should actually be low (though it generally does not have much of a relationship with the LVEDP in that setting). The college include cardiogenic shock in their answer, which one one hand is reasonable because it certainly describes "the above clinical and hemodynamic presentation". However on the other hand, cardiogenic shock is what you get as the result of any number of possible pathologies, i.e. it describes a constellation of clinical features rather than any specific aetiology. One might argue that the question is worded in a way which requires a list of such aetiologies. One possible list could include:
Quintana, E., et al. "Erroneous interpretation of pulmonary capillary wedge pressure in massive pulmonary embolism." Critical care medicine 11.12 (1983): 933-935.