Correct!
5. All of the above
In order to differentiate the type of shock all may be necessary (1). Initially, there was high suspicion for a massive pulmonary embolism and CT/Angio of the chest with contrast was obtained to evaluate this further (Figure 1).
Figure 1. Representative image from the thoracic CT with contrast showing an anterior mediastinal mass (blue star) associated with extensive infiltration around the interatrial septum (red arrow) and under the pericardium.
The results were negative for pulmonary embolus but did reveal an anterior mediastinal mass associated with extensive lipomatous infiltration around the intra-atrial septum and under the pericardium, with evidence of right atrial and ventricular compression (Figure 1).
A point of care (POC) ultrasound of the heart demonstrated significant inspiratory collapse with near total occlusion of the venous inflow into the right atrium, which responded well to increased preload through volume resuscitation and decreased positive end expiratory pressure. he was extubated the same day, which further improved his systemic hemodynamics.
In addition, the POC ultrasound revealed an increase in the size of the interventricular septum (Figure 2).
Figure 2. Left: Static image form point of care ultrasound showing a markedly widened vetricular septum of about 1.8 cm (normal < 1.1 cm). Right: video loop of POC ultrasound of the heart showing a 4-chamber
What is the most likely diagnosis? (Click on the correct answer to be directed to the fourth of six pages)