An unexpected etiology of generalized weakness

A 71-year-old woman with breast cancer presented to the emergency department (ED) with generalized weakness. Presenting vitals were blood pressure 130/66, respiratory rate 30, heart rate 122, T 39.4°C, and O2 sat 98% on room air. Symptoms and vitals initially improved with fluid bolus and acetaminophen; however, she progressively became hypotensive. An additional 500 cc fluid bolus and broad-spectrum antibiotics were given. Labs were significant for aspartate transaminase (AST) 364, alanine transaminase (ALT) 242, sodium 129, and lactate 3.6 despite fluid resuscitation. Vasopressors were started given concern for septic shock and point of care ultrasound (POCUS) was performed. POCUS revealed a markedly dilated right atrium and right ventricle1, 2 (Figures 1 and 2). Parasternal short view revealed evidence of D-sign, indicative of elevated right ventricle pressure1 (Figure 3). Using color doppler, severe tricuspid regurgitation was visualized given the jet size taking up a majority of the atrium2 (Figures 4 and 5). A plethoric inferior vena cava was also noted (Figure 6). Computed tomography angiography (CTA) chest and computed tomography (CT) abdomen/pelvis showed further evidence of fluid overload with bilateral pleural effusions without pulmonary embolism. These findings with the above labs suggest right heart failure with congestive hepatopathy and mixed cardiogenic and septic shock. She was transferred to the ED-ICU where she required diuresis and norepinephrine, cardiology consultation, and eventual admission to the cardiology service. The use of POCUS was critical in identifying the patient's shock etiology in order to help differentiate distributive, cardiogenic, or obstructive shock.3, 4 The use of POCUS was also valuable in guiding management away from fluid resuscitation and instead toward diuresis.3, 4