Saturday, October 22, 2016

Sepsis with Pulmonary Edema and Elevated Right Sided Pressures


I was reading from our list of unconfirmed ED ultrasounds and saw a cardiac ultrasound with good LV function, but with B-lines of pulmonary edema, pleural effusions, and a very dilated inferior vena cava. 

So I went to look at the chart.

It was a chronically ill patient with sepsis, a heart rate of 120, presumed sinus tachycardia, and did not have chronic renal insufficiency.

But there was no ECG recorded.

It did not make sense to me that someone who was septic would have ultrasound evidence of fluid overload unless they had renal failure, which this patient did not.

Then it turned out that an ECG was recorded upstairs, but only after admission:
What is it?


















This is atrial flutter at a rate of 120.
This was not only recorded late, but misread as sinus tachycardia.
The giveaway is the upright P-wave in lead V1.
Sinus P-waves always have a negative component.  The right atrial component comes first and is upright, the left atrial component comes next and is negative, such that the P-wave in V1 should be biphasic.  Upright P-waves in V1, as in this ECG, are classic for atrial flutter.


See these posts for slow atrial flutter:

--Tachycardia with Pericardial Effusion


Discussion
The clinicians probably did not consider that tachycardia at a rate of 120 in a septic patient might be something other than sinus tachycardia.  

Just recording a 12-lead on an ill patient may reveal the unexpected.  Atrial flutter commonly comes in atrial rates as slow at 240 (and ventricular rates as slow as 120), and even slower in the presence of sodium channel blocking drugs.

Also, pulmonary edema should raise high suspicion of a cardiogenic cause, and this is due to either pump function (systolic vs. diastolic), valvular dysfunction, or dysrhythmia.  The patient had good pump function, and sepsis usually leads to volume depletion, or relative volume depletion.  Thus, the pulmonary edema had to be either noncardiogenic (or pneumonia), or due to either dysrhythmia or valvular disease.

Most dysrhythmias are easily diagnosed by ECG.

Learning Points:

1. Always record a 12-lead on a sick patient
2. Flutter can be at rates much lower than you expect.
3. Flutter often mimics sinus tachycardia
4. Fluid overload must be explained, and a cardiac cause is very likely.  This is especially true in clinical situations in which volume depletion is expected.


6 comments:

  1. Didn't get that far (V1) I just saw lead II and noticed the iso electric line was off with the p waves,and ... I love this site, lol.

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  2. what is your suggested management in this complicated case?

    ReplyDelete
    Replies
    1. I would probably electrically cardiovert, accepting the risk of embolic stroke, as the patient is so ill.

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  3. Hi
    Does this all hang together?
    You are describing right ventricular failure in addition to pulmonary edema due to either cardiogenic (elevated LV end diastolic pressures) or non cardiogenic causes. Atrial flutter with normal systolic function in the absence of for example diastolic dysfunction would seem an insufficient explanation of the findings.
    Your thoughts?
    Thanks for the post.

    ReplyDelete
    Replies
    1. The most common cause of RV failure is LV failure. In a sick patient, atrial flutter is definitely sufficient to result in elevated left sided pressures, with pulmonary edema and then subsequent right sided fluid overload. There are only 4 causes of LV failure: valve (valves were ok), systolic dysfct (it was good enough), diastolic dysfct (no evidence of this) and dysrhythmia (this was present). Turns out it had been present for a week, resulting in slow accumulation of fluid (this also explains the pleural effusions).

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