Clinical CT - May 2017

A 54-year-old woman with history of gastric band surgery and 10 years of uncontrolled hypertension has had 4 weeks of progressively increasing abdominal girth, exertional dyspnea, and dependent edema. Today, the patient has dyspnea at rest with epigastric pain. Her blood pressure is 180/90 mmHg, heart rate is 96 bpm, respiratory rate is 28 per minute, oxygen saturation on room air is 97%, and temperature is 98.7 F.

Two slices of her abdominal CT are shown.

Please interpret this CT scan

This is an axial view of the abdomen through the liver. Ascites is present. There is early enhancement of dilated hepatic veins and IVC with reflux of contrast from the right atrium. Peripheral areas of the liver display delayed enhancement, and the liver parenchyma displays a mottled pattern.

What is the most likely etiology of these findings?

The most likely cause of this patient’s presentation is congestive heart failure, specifically, right ventricular failure.

What are the fundamental goals of ED management in this patient?

Support airway, breathing, circulation.
Identify all acutely life-threatening pathologies.
Disposition to safest environment: If respiratory distress has been stabilized, admit to internal medicine. Otherwise consider respiratory step-down or MICU. If there is concern for malignant dysrhythmia or acute ischemia, consider CCU.

How would you manage this patient in the Emergency Department?

Support airway, breathing, and circulation.
Evaluate for STEMI or malignant dysrhythmia with ECG/cardiac monitor.
Reduce cardiac afterload.
Determine whether the patient has pure RV failure or combined LV/RV failure.
Assess preload and consider increasing or decreasing preload with fluids or vasoactive agents.
Provide aspirin if acute ischemia is suspected.
Evaluate for additional causes of acute dyspnea such as pulmonary embolism, aortic dissection, cardiac tamponade, pneumothorax, pneumonia, etc.
Consult cardiology in cases of acute ischemia, malignant dysrhythmia, descending aortic dissection, and cardiac tamponade.

What are the likelihood ratios for various physical exam findings, radiography, and labs in diagnosing acute CHF?

Please review the following chart :

Dyspnea Due to Heart Failure (Without Chronic Respiratory Disease)

What is this patient’s disposition?

The most likely disposition is a telemetry unit under the care of internal medicine.

References

Martindale JL, Wakai A, Collins SP, et al. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2016;23(3):223-42.

https://radiopaedia.org/articles/passive-hepatic-congestion

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