Medical Image of the Week: Pulsus Paradoxus

Figure 1. Arterial line (red) showing pulsus paradoxus.

A 75 year-old man was admitted for suspected septic shock and acute renal failure requiring hemodialysis. He did not required mechanical ventilation. An arterial line was placed and he was found to have pulsus paradoxus (Figure 1). A transthoracic echocardiogram showed early right atrial diastolic collapse consistent with cardiac tamponade and he underwent a pericardial window.

Pulsus paradoxus is the drop in more than 10 mm Hg of systolic pressure during the inspiratory phase (1). Causes of pulsus paradoxus include cardiac tamponade, constrictive pericarditis, severe asthma and chronic obstructive pulmonary disease, restrictive cardiomyopathy, tension pneumothorax, tracheal compression, and circulatory shock (2). With early recognition of this clinical sign, prompt treatment of the underlying etiology can produce a more desirable outcome.

Choua Thao MD¹, Mohanad Hasan MD¹, Hamayon Babary MD¹, and Carmen Luraschi MD²

University of Nevada School of Medicine: Las Vegas

¹Department of Internal Medicine

²Division of Pulmonary and Critical Care

Las Vegas, NV

References

1. Hamzaoui O, Monnet X, Teboul JL. Pulsus paradoxus. Eur Respir J. 2013;42(6):1696-705 [CrossRef] [PubMed]
2. Swami A, Spodick DH. Pulsus paradoxus in cardiac tamponade: a pathophysiology continuum. Clin Cardiol. 2003;26(5):215-7. [CrossRef] [PubMed]

Cite as: Thao C, Hasan M, Babary H, Luraschi C. Medical image of the week: pulsus paradoxus. Southwest J Pulm Crit Care. 2015:11(3):116. doi: http://dx.doi.org/10.13175/swjpcc093-15 PDF

Medical Image of the Week: Acute Aortic Dissection

Figure 1: Panel A: Axial view of the thoracic CT angiography showing aortic dissection in descending aorta where the true lumen (yellow arrow) with outer-wall calcification (red arrow) as well as false lumen with contrast (orange arrow) is seen.  Panel B: Coronal view showing the true (T) and false (F) lumen.

An 85-year-old gentleman with the past medical history significant for hypertension, smoking, and coronary artery disease presented to the emergency department (ED) with complains of sudden onset of chest pain.  His pain was described as squeezing and radiating to the back, associated with nausea and vomiting. His chest pain improved with nitroglycerin in ED.  Chest x-ray showed a tortuous aortic knob and widened mediastinum.

He underwent a CT angiogram, which showed, Stanford Type B aortic dissection, from distal aortic arch to renal arteries (Figure 1).  He was managed in the hospital conservatively with tight blood pressure control given the type of dissection and no surgical intervention was done. He was uneventfully discharged with follow up arranged with vascular surgery.

Aortic dissection is classified by Stanford Criteria as Type A which involves the ascending aorta and arch and Type B when it involves the descending aorta. Type A dissection is a surgical emergency and guidelines suggest medical / non-surgical management for Type B dissection except in cases where the pain is not controlled despite BP control, acute expansion of the false lumen, peri-aortic hematoma or distal mal-perfusion.

Hem Desai MD¹, Aung Bajaj MD¹, Kamalani Hanamaikai MD¹ & Bhupinder Natt MD²

¹Department of Internal Medicine and the ²Division of Pulmonary, Allergy, Critical Care and Sleep Medicine  

University of Arizona

Tucson, AZ USA

References

1. LePage MA, Quint LE, Sonnad SS, Deeb GM, Williams DM. Aortic dissection: CT features that distinguish true lumen from false lumen. AJR Am J Roentgenol. 2001;177(1):207-11. [CrossRef] [PubMed]
2. von Kodolitsch Y, Nienaber CA, Dieckmann C, Schwartz AG, Hofmann T, Brekenfeld C, Nicolas V, Berger J, Meinertz T. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004;116(2):73-7. [CrossRef] [PubMed]

Reference as: Desai H, Bajaj A, Hanamaikai K, Natt B. Medical image of the week: acute aortic dissection. Southwest J Pulm Crit Care. 2015;10(6):348-9. doi: http://dx.doi.org/10.13175/swjpcc063-15 PDF

Medical Image of the Week: Undulating Arterial Waveform

Figure 1. Arterial line and oxygen saturation tracings demonstrating variability with inspiration, a sign of volume responsiveness.

Volume responsiveness assessed by variation in arterial line tracing demonstrating either stroke volume variation, systolic pressure variation, or pulse pressure variation has been shown to be far superior to traditional static indicators of preload responsiveness as they consider cardiopulmonary interactions (1). Additionally, variability in the O2 sat tracing has also been shown to be a reliable indicator of volume responsiveness (2).  

Jarrod M. Mosier, MD and John W. Bloom, MD

Emergency Medicine-Critical Care Program

Division of Pulmonary and Critical Care

University of Arizona

Tucson, Arizona

References

1. Marik PE, Baram M. Noninvasive hemodynamic monitoring in the intensive care unit. Crit Care Clin. 2007;23(3):383-400. [CrossRef] [PubMed]
2. Feissel M, Teboul JL, Merlani P, Badie J, Faller JP, Bendjelid K. Plethysmographic dynamic indices predict fluid responsiveness in septic ventilated patients. Intensive Care Med. 2007;33(6):993-9. [CrossRef] [PubMed] 

Reference as: Mosier JM, Bloom JW. Medical image of the week: undulating arterial waveform. Southwest J Pulm Crit Care. 2013;7(5):315. doi: http://dx.doi.org/10.13175/swjpcc153-13 PDF