Code Blue II

The patient described in the last blog had initially come in with cardiogenic shock of unclear etiology. His troponins were modest, but he had a severely depressed ejection fraction in a normal sized heart. His hemodynamics were so bad that he went into multi organ failure with shock liver, acute renal failure, and respiratory failure requiring intubation. His clinical course was complicated by heparin-induced thrombocytopenia and bilateral deep vein thromboses. He was put on argatroban for clot prevention. He slowly made a recovery; we were able to extubate him, we weaned down sedation, his laboratory abnormalities were normalizing. But then the next day he coded and died. As we got serial ABGs, we realized the patient had a large A-a gradient suggestive of a massive pulmonary embolus. We pushed t-PA but there was really nothing more we could do.

We got an autopsy on this patient. I blogged a long time ago on autopsies; the last I attended was two years ago. I think they are an invaluable resource. We didn't know the diagnosis; we didn't know why his heart went bad at the start and our theory of pulmonary embolus was hypothetical. But going down to examine the organs was incredibly enlightening. We were able to see the wedge infarcts and visualize the clot burden. We were able to hold the heart in our hands and feel it. We were able to confirm our diagnosis of why the patient coded, and as soon as the pathologists complete their microscopic analysis, we'll have a better sense of why he had cardiogenic shock in the first place.