A 50 year-old-female with a history of non-ischemic cardiomyopathy, congestive heart failure, and ventricular dysrhythmias with an ICD in place came into our ED with complaints of lightheadedness. The lightheadedness was worse with standing. The patient denied CP, SOB, fevers, cough, dysuria, vomiting, diarrhea, and rectal or vaginal bleeding. She reported that she had not had any episodes of syncope and her ICD had not been triggered. She denied increased LE edema and weight gain.
Initial VS: BP 78/53, HR 89, T 36 °C (96.8 °F), RR 20, SpO2 98%
Physical exam revealed a patient in no apparent distress, sitting back in bed. Breathing was non-labored and no crackles were appreciated. 2+ bilateral pitting LE edema was noted to the level of the knees.
Chart review revealed that her normal BP was approximately 90/50.
It would have been easy to empirically give the patient a bolus and reevaluate. Fortunately, the team decided to evaluate the patient’s fluid status with ultrasound.
In our emergency department, we prefer to look at the heart, lungs, and IVC when trying to assess fluid status as it gives a more complete picture than just one variable alone.
Here is what her heart looked like:
The patient has severely decreased global LV systolic function, but patients with poor function can sometimes be fluid down, so don’t stop looking when you see this.
Here is what her IVC looked like:
The IVC appears dilated and has no respiratory variation. This correlates with plenty of pre-load. After seeing this, the providers thought that maybe giving fluids was not such a good idea, but still wanted a little more information.
Here are what the lungs looked like:
There are b-lines (artifact from edema in the lungs) present bilaterally. All of the findings made it obvious to the providers that this hypotensive patient was actually fluid up and that giving IVFs would probably make the patient worse.
The patient was evaluated for other causes of hypotension but was ultimately felt to have cardiogenic hypotension. This case illustrates the portability and speed in diagnosing both decreased inotropy and pulmonary edema that benefits the patient over traditional methods. Ultrasound is not only more sensitive and intuitive, but faster.
Her BNP was 1504.
The patient was started on diuretics and admitted for ongoing management of her cardiogenic shock. As an inpatient, she was started on dobutamine and then also levophed while being aggressively diuresed. The patient improved clinically and at the end of her hospital stay was net -18L of fluid.
