A 68-Year-Old Man with Acute Respiratory Failure and Hypotension

Abstract

A 68-year-old man developed acute, severe dyspnea while convalescing at an adult family home after a hospital admission for pneumonia. On transfer by paramedics to the emergency department he was noted to have shock and severe hypoxemia. Bedside ultrasound revealed a severely dilated right ventricle, prompting a therapeutic intervention. Case VignetteA 68-year-old man with a past medical history of hypertension, hemorrhagic stroke, and tobacco use and a family history of coronary artery disease was convalescing at an adult family home after a recent hospital admission for community-acquired pneumonia when he was noted to develop acute dyspnea. On arrival at his residence, the paramedics found the patient moaning, with a Glasgow Coma Scale score of 8 and increased work of breathing.On arrival at the emergency department, his temperature was 36.2 8 C; heart rate, 47 beats/minute; blood pressure, 97/56 mm Hg; respiratory rate, 36 breaths/minute; and he had an oxygen saturation of 70% while he breathed oxygen via a nonrebreather mask. The patient was intubated on an emergency basis. Physical examination after intubation and initiation of sedation revealed a wellnourished, unresponsive man. The trachea was midline and lungs were clear to auscultation. Cardiac examination revealed regular bradycardia, no precordial heaves, and a grade III/VI holosystolic murmur along the left sternal border, which had not been noted during his previous hospitalization. There were diminished dorsalis pedis and radial pulses and his skin was cool to palpation. The abdomen was soft, nontender, and without organomegaly. There was no asymmetric lower extremity edema.