Muhammad Fuad Bangash, MD,, FCCP
Chief, Pulmonary& Critical Care
Medical Director, ICU
Steward Norwood Hospital
Norwood, MA 02062, USA
E-mail:
lifesavericu@icloud.com
It was a cold December night in Minneapolis, Minnesota. I was in ICU taking care of a patient, Mr. David, who had had a cardiac arrest at home, underwent CPR and was now on mechanical ventilation. He had been subjected to ‘Mild Induced Hypothermia’ protocol. The patient did well and after re-warming to normal temperature, he was weaned off sedation and mechanical ventilation. He was able to talk and move all his extremities. This is what we hope for in every patient after a cardiac arrest with appropriate medical care and latest technology. Patients get a second lease on life and their loved ones are able to look into their eyes and hold their hands. David’s wife Mary was so happy to see him come around after she had witnessed him undergoing CPR.
Everything was going well but we were puzzled that why David’s heart had stopped in the first place. Since he was stable now, we called the cardiologist, who performed cardiac catheterization, found a blockage and placed a stent.
Shortly after coming back to the ICU from the cath lab, patient became very unstable. There were signs of hypoxia and a very low blood pressure. I placed a breathing tube and started pumping IV fluids. An emergent echocardiogram confirmed collection of blood in the pericardium – there was cardiac tamponade. The cardiologist drained the blood and patient’s condition became stabilized.
He had to undergo cardiac surgery to evacuate all the blood and to repair the heart vent, again to
Be kept under sedation and mechanical ventilation despite doing well earlier that day. Fortunes had changed for the worse within a few hours. David’s wife was very distressed. The ICU team reassured her. Eventually, David was able to be weaned off sedation and mechanical ventilation, made a full recovery after rehab and was discharged home.
Pericardial tamponade is a ‘can’t-miss-it critical care catastrophe’ and needs to be managed immediately. If missed, it is rapidly fatal. I had two other cases where the cause was postcardiac surgery hemorrhage and a malignant pericardial effusion.
The key signs are hypotension, tachycardia and distended jugular veins. Additional signs include a flask like silhouette on chest x-ray, low voltage on ECG and pulsus paradoxus.
If the shock cannot be explained by history and physical examination, an emergent echocardiography will show the typical signs of pericardial effusion and RV collapse. Treatment can either be pericardial drain placement or making a pericardial window.
MY MOST MEMORABLE PATIENT
Suspect; Act; Save
Muhammad Fuad Bangash MD, FCCP,
Chief, Pulmonary& Critical Care
Medical Director, ICU
Steward Norwood Hospital
Norwood, MA 02062, USA
E-mail:
lifesavericu@icloud.com
This case left a lasting mark on my memory. Susan, 72 years of age, female patient presented to ED with shortness of breath and fever. Chest x-ray showed right sided pneumonia and effusion. She was put on appropriate IV antibiotics and a small bore chest tube was placed under ultrasound guidance. Since the effusion did not drain freely a combination of tissue plasminogen activator (TPA) and dornase alpha (an inhaled drug for treating cystic fibrosis) was used by the consulting pulmonologist.
Despite appropriate antibiotic therapy and drainage, patient’s condition worsened requiring mechanical ventilation and vasopressors. Patient was becoming frailer day by day due to malnutrition and also developed congestive heart failure.
Our cardiothoracic surgeon performed a video assisted decortication on the right side. Biopsy specimens were sent from the lung and pleura. The pathologist identified unusual gram positive filamentous bacteria. It was recommended that Bactrim be used IV for possible Nocardia infection. Patient condition gradually started to improve with enteral nutrition, diuresis, and was extubated but required a prolonged ICU stay, followed by rehabilitation.
The pleural fluid culture eventually grew Actinomyces Israeli! It was a case of a very unusual cause of pneumonia. The aggressive care with thoracic surgery, mechanical ventilation and antibiotics guided by biopsy specimens, saved Susan!
Unusual pulmonary infections are a ‘Can’t Miss Critical Care Catastrophes’; although rare but can prove fatal. So although our traditional approach to community acquired or healthcare associated pneumonia is enough in most patients, if they are not responding then appropriate consultations coupled with appropriate diagnostic / therapeutic procedure will save lives!