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A lady with acute SOB

A lady with acute SOB. Sammi Pe. Case Presentation. 54/F Cat II BP 129/69mmHg P 128 Temp 36.9 SpO2 78% ( 100% O2) Triage : SOB since afternoon, cough with sputum, mild chest discomfort. What will you do ?. What further history need?. What further Hx. Good Past Health Domestic helper

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A lady with acute SOB

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  1. A lady with acute SOB Sammi Pe

  2. Case Presentation • 54/F • Cat II • BP 129/69mmHg P 128 • Temp 36.9 • SpO2 78% ( 100% O2) • Triage : SOB since afternoon, cough with sputum, mild chest discomfort

  3. What will you do ? What further history need?

  4. What further Hx • Good Past Health • Domestic helper • SOB since ~2 hrs ago • Mild cough with yellowish sputum xdays become blood stained on AED • No fever • Chest discomfort today ( tightness) • Palpitation +ve

  5. More hx from employer • Mild exertional SOB x several days • Need resting after her work • No fever all along • No Travel hx • Work in HK x ~17yrs • No GI upset/ abd pain • Not on regular medication • Non-smoker, non-drinker

  6. P/E • Alert GCS 15/15 • BP 139/78 P 120 • RR 48 • Sit up for breathing • SpO2 80% on 100% O2 • Recheck Temp 37.2 • H’stix 13.2

  7. P/E • Chest: AE fair with bilateral basal crep, occ wheeze • Abd soft • HS dual, no murmur • No ankle edema

  8. What will you do next ?

  9. ABC • 100% O2 mask • HB set • Blood x CBC, L/RFT, Trop I , Clotting • ECG • i stat ( arterial) • CXR

  10. ECG x 2

  11. i stat (arterial, on 100%O2) • pH 7.398 • pCO2 5.39 kPa • pO2 5.8 kPa • BE 0 • HCO3 24.9 mmol/L • SO2 79% • Na 141 K 3.5 i Ca 1.21 Hb 14.6

  12. Our Patient Problem: Sudden onset SOB Desaturation even on 100% O2 Type I Resp Failure What is yr DDx?

  13. Type I Resp Failure Typically due to V/Q mismatch PaO2 low (< 60mmHg(8.0kPa)) PaCO2 normal or low PA-aO2 increased • Parenchymal disease (V/Q mismatch) • Diseases of vasculature and shunts: right-to-left shunt, pulmonary embolism • interstitial lung diseases: ARDS, pneumonia, emphysema.

  14. Patient was still in distress even on 100% O2 What will you do then?

  15. Patient was put on CPAP • Lasix 40mg iv • BP 110/70 • Clinically improved • CXR film A/V….

  16. CXR What is yr Diagnosis?

  17. APO …. ? Other drug(s) to be considered? Underlying cause CCU was consulted

  18. Medications… • Nitrates • Vasodilation • Reduced preload and afterload • Improved CO • Rapid effect • Not prescribed likely due to BP on low side • Diuretics • Reduced plasma volume / preload • Pulmonary vasodilatation • ACEI • Reduced afterload • Improved CO

  19. Underlying Causes • ACS • HT • Aortic/mitral valve disease • Arrhythmias • VSD • Cardiomyopathy • Acute myocarditis • Pericardial disease • Atrial myxoma • Echo was performed…

  20. Our case What is show in the Echocardiogram?

  21. CCU input • ECHO: • LA mass ~4cm • Likely atrial myxoma • Trivial MR/AR • Normal LV size and EF

  22. Our Patient APO secondary to large atrial myxoma • Transfer to CCU then CTSU for further Mx.

  23. Progress • Emergency excision of atrial myxoma • 6x5cm encapsulated LA tumour attached to inter-atrial septum. • Causing obstruction & pul edema • Bi-atrial exploration + excision of tumour • Extubated on D1 • Post-op echo: EF 70% • no PE

  24. Day 0 Day 1 Day 2

  25. Day 3 Day 4 Day 20 Patient was discharge on D8 and SOPD FU On Day 20 Good Recovery, Class I II , ET 3-4 FOS

  26. Atrial Myxoma

  27. Background Most common 1° Heart tumour (40-50%) 90% solitarty and pedunculated • Multiple tumours occur in 50% of familial case 10% familial ( autosomal dominant) 75-85% occur in LA ~25% RA Attach to fossa ovalis Symptomatic ~ 70g 140g

  28. Myxoma- • polypoid, round, oval in shape • Smooth / lobulated surface • White/ yellow/ brown • Produce numberus growth factors and cytokines e.g. interleukin-6

  29. Histology • lipidic cells embedded in a vascular myxoid stroma • In a series of 37 cases, • 74% of tumors showed immunohistochemical expression of interleukin-6 while • 17% had abnormal DNA content

  30. Epidemiology • US ~ 75 case / million autopsies • 75% sporadic – Female • Mean age – 56 • 15% present as sudden death • tumour embolism, HF, mechanical obstruction

  31. History Asymptomatic (20%) symptomaticsudden death (15%) Mechanical interference with cardiac fxembolization LHF RHFsystematic (L) Pulmonary (R) Exertional SOB fatigueinfarct / haemorrhage PE Orthopnea peripheral edema of viscera Pul infarction PND ascites e.g. CVAPul HT Pul edema visual loss Postural dizziness Constitutional symptoms : fever, Wt loss, arthralgias, Raynaud ~ 50% of patient due to interleukin-6 overporduction

  32. Physical • ↑JVP • Loud S1 ( delay mitral valve closure) • Early diastolic sound (Tumor plop)tumor hit against the endocardial wall • Diastolic atrial rumble ( obstruction in MV) • MR/ TR ( valvar damage/ prolapse)

  33. DDX • Mitral Regurgitation • Mitral Stenosis • Pul Embolism • Pul HT , primary • Tricuspid Regurgitation • Tricuspid Stenosis

  34. Ix • Lab: ESR, CRP, CBC, serum interleukin-6 • CXR • ECHO • need to differentiate thrombus from myxoma • Thrombus ( in posterior portion, in layers) • Myxoma ( presence of stalk and mobility) • MRI (point of attachment ) • CT scan

  35. Treatment • Medical treatment for CHF and arrhythmia • Surgical excision is the definitive tx • Safe and curative • Recurrence is possible if incomplete excision

  36. Thank you

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