72 yo female "my doctor told me to come in"

[pbruss]

the other day at toled i got a call from a local pcp about a patients she was sending in. "i want ehr evaluated for CHF, she has sob and edema which is new. call me back when the BNP is done."

most of the teh history id from her husband. for past week she has had chest congestion and productive cough. 3 days ago she was having a couginh "fit" then complained of worsening sob and pressure in her face and neck. she can not lay flat at night because she can not breath. her PCP started her on levaquin 7 days ago, she saw her in the office and she directed her by private car to go to the ER. she smokes has history of CAD, HTN, HLD, COPD, PVD. on asa, plavix, coumadin.

exam - p-130, t-37, BP-114/75, O2-80%RA, R-35
general - sever resp distress, tripoding, somulent but talking, confused and agitated.
ent - sever edema in neck and face - pitting - eyes swollen shut. audibale inspritory and expritory strodor with right tracheal deveation. no crepitence. no tounge swelling
lungs/CV - tachy but regular, 3/6 holosytoloc murmer. tachynepic with mild scattered expritory wheezes. bilat breath sounds, no rales.
ABD - normal
EXT - cyanotis but no edema.

Based on H/P what is the first step in mamagment?

A. needle decompression of left lung
B. intubation
C. bedside pericardialcentesis
D. Racemic epi neb
F. IM epi

After your first step what would be the most usefull initial diagnostic test to guide managment?

A. CXR
B. soft tissue neck xr
C. ct neck
D. ct chest
E. EKG
F. stat echo

[tyson]

I would say A and then A

sounds like coughing fit set off pnuemothorax (pt has risk factors has risks factors) which progressed into tension pnuemo. possible causing SVC syndrome (you can get edema and wheezing w/ this stuff).

obviously potential other etiologies here, but can't get around the tracheal deviation otherwise.

[pbruss]

good thought but no. she has equal breath sounds and PTX does not cause stridor. spot on with the SVC syndrome. care to change your answer or anyone have an idea?

[tyson]

okay, go #2

ascending aortic aneurysm. these can cause tracheal deviation. also can extend down causing tamponade (she's tachy, relatively hypotensive for her age, has aortic murmur (new?)) and symptoms of SVC.
so the C and F.

[hackman]

I think she might be stridorous from a some neck mass or expanding hematoma from coughing fit (on plavix and Coumadin) which could also deviate her and cause SVC syndrome, I say tube her and get a CT neck.

[slevittMD]

I'd say intubate and then CT chest.
She's got airway compromise, evidenced by the stridor, so she needs a stable airway.
CT chest is the best way to find the cause of the SVC syndrome (although if I were actually ordering this test, I'd probably do neck and chest)

[pbruss]

1 intubate. has unstable air way. on boards ALWAYS choose this option when any concern for airway. i can see the appeal of needle decompression ad preicardialcentesis. but has equal breath sounds and stridor. remember she is on coumadin and her pcp put her on levaquin which messes up inr. her int ended up being 6.

2. packman is exactly right. this was SVC syndrome. turns out she ruptured her aorta and had a hematoma pushing on everything. see attachment. aorta is red, hematoma is blue, trachea is black which is pushed to the right

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