This patient presents to the Emergency Department with palpitations, generalized weakness, and shortness of breath after discontinuing all her home medications. She has hypotension, marked tachycardia, and pulmonary edema (crackles on lung auscultation). The 12-lead EKG demonstrates atrial fibrillation with a rapid ventricular rate. This patient is in a state of cardiogenic shock and requires prompt oxygen support, blood pressure support, and heart rate control.
Pulmonary embolism (Choice A) can sometimes manifest as new atrial fibrillation with shortness of breath and tachycardia, but pulmonary embolism initially causes obstructive shock. If a pulmonary embolism goes untreated, it can progress to right ventricular failure, pulmonary edema, and cardiogenic shock. This patient has known atrial fibrillation and stopped all her home medications. The abrupt medication change is a more likely cause of the patient’s cardiogenic shock. Dehydration (Choice D) and systemic infection (Choice D) are less likely given the above history of abruptly stopping home maintenance medications. Untreated cardiac arrythmia (Choice B) is the most likely cause for this patient’s pulmonary edema and cardiogenic shock.
The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.
Joey Ciano, DO, MPH is an Emergency Medicine Physician from New York, USA. He completed his Emergency Medicine Residency in Brooklyn, NY and a Fellowship in Global Emergency Medicine in the Northwell-LIJ Health System. He is interested in building the educational infrastructure of EM in countries where EM is not yet recognized as a field and in countries that are in the early stages of this process. He has partnered with international NGOs in EM educational projects and works as a visiting EM faculty member in West Bengal, India. He is excited to collaborate with the other authors of the iEM Education Project to contribute to world of FOAM-ed.
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