03:00 14th October 1937 A&E Storifield Hospital
It was a quiet night when the Resus phone went off. “We have a 59 year old male who developed sudden onset of shortness of breath an hour ago. He was “tripoding” when we arrived and saturations were 81% on air.On 15L SpO2 are 89%. He had no history of chest pain , cough, fever or any other medical conditions. Wife says he smokes a pack of 20 a day. He can obey commands but is unable to verbalise due to severe SOB. Pulse 115,BP 162/75,RR 45/min. We will be with you in 12 minutes.”
So we started our preparation. Possibilities like pneumothorax, asthma attack, pulmonary embolism and a cardiac event were discussed. 2 minutes later, the paramedic called back and said he is now unresponsive on AVPU scale. Bad feeling started to creep in. The speed of his deterioration mimicked ALS exam scenario. The patient arrived. I did the primary survey.
B:Silent chest bilaterally. Minimal expansion, symmetrical, Trachea central. SPo2 83% on 15L NRB. No stigmata of tension pneumothorax
C:Cold peripheries. P 123/min BP 162/89 S1+S2 audible
D: E1M4V1 Pupils 5 mm Bilateral and equally reactive.
E:NAD Temp 36.1
ABG: pH 6.98, pCO2 16.02 kPa, pO2 21.7 kPa, HCO3 27.8 mmol/L, base excess −7.5, lactate 2.7
BVM ventilations were initiated.He was cannulated and IV fluids started. RSI performed. Grade I intubation.
12 lead ecg and CXR were done next.
In the presence of silent chest,type 2 respiratory failure and no obvious pneumothorax on the x-ray, he was given 500mcg IV salbutamol but with a question that this patient had no prior history of asthma.Xray and ECG couldn’t explain the patients condition.
A RUSH(Rapid Ultrasound in Shock) was performed looking at the heart IVC and AAA. Echo clip is shown here.
A suggestion to perform CT head was discussed. But with a clear history of shortness of breath ,globally hypokinetic left ventricle and a GCS that dropped later, a collective decision to activate the cath lab was taken without performing a CT head. Angiogram showed severe left main stenosis which was successfully stented
So summing it up, this man had an occlusion of left main causing acute coronary syndrome and global hypokinesia of left ventricle leading to flash pulmonary edema. This led to severe bronchospasm , the silent chest and respiratory.
He was discharged home a week later.