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

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