Thanks to The Lilac Master @sudalisd for the quality of the cases.~
Patient: Female, 74 years.
Complaints: Sudden shortness of breath for 1 hour, cardiac arrest 1 time.
The patient suddenly has shortness of breath, can not lie flat, sit and breathe, cough pink foam sputum, the family then called 120 to the hospital for treatment, on the way the patient has loss of consciousness, heartbeat, respiratory arrest, cardiopulmonary resuscitation, to static adrenaline, electrical defibrillation and tracheal intubation ventilator auxiliary breathing and a series of rescue after about 10 minutes the patient resumed spontaneous heartbeat, but still unconscious, sent to the ICU for further diagnosis and treatment. Other symptoms are unknown.
Medical history: Previous history of "hypertension grade 3, type 2 diabetes", regular use of antihypertensive drugs and hypoglycemic drugs, irregular monitoring of blood pressure and blood sugar.
Post-rescue physical examination: body temperature 35.5 °C, pulse 119 breaths/min, breathing 16 breaths/minute, blood pressure 85/55 mmHg. Fingertip pulse oxygen 97% (ventilator support). Delirium, bilateral pupils are large iso-circles, the pupil diameter is 3 mm, and the reflection to light disappears. Jugular veins are angry. Both lungs have coarse breath sounds, and both lungs can hear more wet rales, but no dry rales.
There is no enlargement of the heart, the rhythm is aligned, the heart sound is acceptable, and the tip of the heart can be heard with a 4/6 systolic jet-like murmur. There is no edema in both lower extremities. The abdomen is flat and soft, there is no abdominal muscle tension, and the bowel sounds are weakened. Extremity muscle strength and tone examination cannot be coordinated. Pathological signs are not elicited, physiological signs are present.
Laboratory test: peak ultrasensitivity troponin T: >50,000 pg/mL ( 0 - 34.2 ). CK-MB：227.8 U/L（0 - 25）；CK：1554 IU/L（25 - 173)。 pro - BNP 5697.41 pg/mL。 Blood gas analysis: pH: 7.0, PCO2: 46 mmHg, PO2: 59 mmHg, HCO3: 11.3 mmol/L, lactic acid: 8.7 mmol/L.
Blood count: leukocytes 18.12 x 10^9/L, percentage of neutrophils: 45.7% (50 - 70), percentage of lymphocytes: 48.5% (20 - 40), no abnormalities. QR - CRP：45 mg/L（0 - 10）。
Serum potassium: 3.68 mmo/L. D-dimer: 14810 ug/L (0-1000). Blood glucose 29.1 mmo/L. Serum β oxybutyric acid (BHB) measured is normal. Glycosylated hemoglobin: 7.5%. There were no obvious abnormalities in renal function, liver function, blood lipids, and A function.
Electrocardiogram after rescue, see the following figure:
Bedside chest x-ray after rescue, see the picture below:
Ct of chest enhancement after rescue, see figure below:
Emergency coronary angiography results: no stenosis was seen in the left main trunk and anterior descending branch, right crown, and gyratory branch, and the anterior descending branch was small, and TIMI blood flow was grade 2 to 3.
Simple bedside cardiac ultrasound after rescue: thickening of the ventricular septum and left ventricular wall, left atrium 38 mm (20 to 35), small remaining avioventricular cavity, normal left ventricular systolic function, EF 59%, decreased compliance.
The patient has such a dangerous onset, direct cardiac arrest, and successful treatment of cardiopulmonary resuscitation, but the hemodynamics are still unstable, and the blood pressure is low, consider what is the disease behind the pusher?
What should be the next step in the diagnosis and treatment strategy? The answer is out