CHEST Guidelines-A-Man-in-his-80s-With-Refractory-Hypoxia-and-Shock

A-Man-in-his-80s-With-Refractory-Hypoxia-and-Shock

Pdf Summary

The case study discusses an elderly man in his 80s with complex medical issues, including advanced dementia, metastatic prostate cancer, and a history of recurrent aspiration, who experienced refractory hypoxia and shock following cardiac arrest. Initially admitted to the emergency department with fever and respiratory distress, the patient was found to have left lower lobe pneumonia. Despite intubation and temporary stabilization, he developed bradycardia, pulselessness, and profound hypoxia, requiring advanced cardiac life support, after which spontaneous circulation was restored, yet his oxygen saturation remained critically low.<br /><br />Subsequent interventions included norepinephrine infusion for hypotension management. A bedside point-of-care ultrasound (POCUS) was utilized to investigate the underlying cause of his critical condition, revealing massive pulmonary embolism (PE) leading to acute cor pulmonale. This condition was exacerbated by a right-to-left intracardiac shunt through a patent foramen ovale (PFO), contributing significantly to the hypoxia.<br /><br />The ultrasound findings ruled out tension pneumothorax and pulmonary edema, demonstrated severely reduced left ventricular function, and indicated increased right atrial pressure due to the PE. The presence of a dilated right ventricle and interatrial septal displacement confirmed the diagnosis. Despite the severe hypoxic condition, thrombolysis was not administered due to his multiple comorbidities, resulting in the patient's death.<br /><br />The case underscores the importance of POCUS in diagnosing complex cardiopulmonary conditions and its role in differentiating the causes of refractory hypoxia. It also highlights how intracardiac shunts like PFO can complicate a PE scenario by worsening hypoxia. Despite advanced echocardiographic and diagnostic tools, the patient's multitude of health issues and PE's critical impact led to an unfavorable outcome.

Keywords

elderly patient

advanced dementia

metastatic prostate cancer

refractory hypoxia

pulmonary embolism

patent foramen ovale

point-of-care ultrasound

acute cor pulmonale

intracardiac shunt

cardiac arrest