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53. Pulmonary Hypertension: “You Take My Breath Away”
Keywords
Pulmonary hypertensionRight heart failureRespiratory distressCardiac emergenciesPulmonary emergenciesCritical careEmergency medicineUltrasoundCase
Flight med calls your department. “We have a 41-year-old cardiac patient of yours with a catheter coming from his chest that has broken off. Blood was coming from it, so we clamped it off. He’s in respiratory distress and we’ll be landing in 5 minutes.”
Pertinent History
The patient is a 41-year-old male with a history of pulmonary hypertension who presents in respiratory distress. The broken line is used for a continuous infusion epoprostenol pump. The patient reports having non-bloody diarrhea for the last 3 days. He endorses nausea but has been tolerating fluids. He had mild SOB starting earlier today. However, just prior to calling EMS he fell due to lightheadedness while attempting to stand up quickly. His epoprostenol line caught on some furniture, causing it to tear. The broken off remainder is still in his chest. He did not lose consciousness or sustain any other injuries. Immediately following his line malfunction, he reports worsening shortness of breath, lightheadedness, and chest pressure.
Pertinent Physical Exam
Vitals: HR 125, RR 28, O2 sat 92% on 15 L/min, BP 102/74.
Except as noted below, the findings of a complete physical exam are within normal limits.
General:
The patient is in acute distress.
Pulmonary:
He is in respiratory distress and is speaking in 4–5-word sentences. Lungs are clear. Tachypneic with mild retractions.
Cardiovascular:
2/6 systolic murmur, JVD to angle of mandible, and a regular rhythm, Extremities with 1+ pitting edema.
Abdominal:
Exam is benign except for mildly increased bowel sounds.
Skin:
Pale, cool, and diaphoretic.
PMH
History of pulmonary hypertension and right heart failure. No other significant medical history. No surgical history.
SH
Patient does not drink alcohol, use illicit drugs, or smoke. Patient worked as a school teacher prior to developing pulmonary hypertension. He is currently on disability.
Pertinent Test Result
Test | Result | Units | Normal range |
|---|---|---|---|
WBC | 10.7 | K/uL | 3.8–11.0 · 103/mm3 |
Hgb | 16.3 | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Hematocrit | 43 | % | 34.9%–44.3% |
Platelets | 264 | K/uL | 140–450 K/uL |
Sodium | 143 | mEq/L | 135–148 mEq/L |
Potassium | 3.3 ↓ | mEq/L | 3.5–5.5 mEq/L |
Chloride | 110 | mEq/L | 96–112 mEq/L |
Bicarbonate | 22 | mEq/L | 21–34 mEq/L |
BUN | 30 ↑ | mg/dL | 6–23 mg/dL |
Creatinine | 1.5 ↑ | mg/dL | 0.6–1.5 mg/dL |
Glucose | 86 ↑ | mg/dL | 65–99 mg/dL |
pH (venous) | 7.2 ↓ | – | 7.320–7.420 |
pCO2 (venous) | 25 ↓ | mmHg | 36.1–52.1 mmHg |
pO2 (venous) | 36 ↓ | mmHg | 46.1–71.1 mmHg |
Lactate | 3 ↑ | mmol/L | <2.0 mmol/L |
Troponin | 0.07 | ng/dl | <0.11 ng/dl |
BNP | 510 ↑ | pg/ml | <100 pg/ml |
Learning Points
- 1.
What symptoms do patients with pulmonary HTN present with during acute episodes?
- 2.
What objective findings can be present in decompensated pulmonary HTN?
- 3.
What are the management goals for treating patient with acute episode of decompensated pulmonary hypertension?
- 4.
What are the treatment options for the management of both an acute-episode and long-term pulmonary HTN?
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