TRIAL SAQ – QUESTION 10

Graeme Thomson

SCENARIO

A 50 years old woman has presented after 2 weeks of lethargy, dyspnoea and pleuritic chest pain. She is now more dyspnoeic and her BP is 80/60. She is currently afebrile. This is her ECG.

QUESTION 1

What is the cause of her hypotension?

CAUSE OF HYPOTENSION

Restricted cardiac output secondary to pericardial tamponade.

QUESTION 2

List 4 positive ECG findings that support your diagnosis.

ECG FINDINGS

Tachycardia

Electrical alternans (QRS)

Small voltages across chest leads

PR elevation AVR

PR depression especially Lead II

QUESTION 3

Describe 5 abnormalities that you could expect to see on a focused ultrasound scan of her heart.

ULTRASOUND FINDINGS

Dark stripe around the heart

Decreased chamber filling

Early diastolic right ventricular collapse

Late diastolic right atrial collapse

Flow variation across mitral and tricuspid valves during inspiration

Dilated, non-collapsing IVC

QUESTION 4

Outline 4 interventions that would be likely to improve her cardiac output.

IMPROVING CARDIAC OUTPUT

Fluid loading

Inotropes

Pericardiocentesis

Pericardial window

Other complex interventions

EXPECTED PASS SCORE

1 out of 1

3 out of 4

3 out of 5

3 out of 4

Total = 10 out of 14

ACTUAL SCORES

Median 10.5

Mode 11

30 candidates > 10

4 candidates = 9

11 candidates < 9

DISTRIBUTION

1 2 3 4 5 6 7 8 9 10 11 12 13 140

2

4

6

8

10

12

14

Scores

Scores

PROBLEMS

ECG interpretation Especially making up abnormalities to support a

diagnosis of PE

Ultrasound knowledge And unrealistic expectations of ultrasound like being

able to measure pressures

And lack of imagination

Following instructions Especially positive ECG findings and improving

cardiac output