ED doctor struggles to discover cause of patient's collapse and paralysis

The patient is a gentleman in his early sixties, moderately obese and comes to me intubated, sedated and paralyzed. I am told that he had a history of stroke and today fell to the ground unconscious.  His initial vital signs are stone cold normal, and I set off a “Stroke Code.” The patient goes through the computed tomography (CT) scanner, and neurology is at the bedside in minutes.  

I review the CT scan of the head but do not see anything that could explain his complete collapse and paralysis.  While in the scanner the patient's BP drops, and I bolus him with two liters of fluid and initiate pressers.  A temperature probe catheter is inserted, and the patient's core temperature came back indicating hypothermia.  Altered mental status, hypotension and hypothermia indicate severe shock.  Chest x-ray, blood, urine, fluid cultures and broad-spectrum antibiotics are added to my order set.  

Thirty minutes have passed and as I order antibiotics, the paramedic inquires as to whether or not I gave tissue plasminogen activator (tPA).  He is still suspecting stroke as the culprit, but the thought of tPA makes me realize that a massive blood clot must have been thrown into the main pulmonary artery, causing the still unexplained syncope and hypotension. I ran into the trauma room, grabbed a portable ultrasound machine and rushed into my patient's room to scan his heart. Immediately, I recognized right-sided heart strain, cinching the diagnosis.  

Forty minutes have passed. I scan my patient's heart and frown. I see no evidence of right-sided heart strain or a pericardial effusion causing tamponade.  As I looked down and towards my left, I realized that my patient's abdomen appears much larger than it had been when he arrived.  I place my hand upon him and feel what the textbooks refer to as a “pulsatile abdominal mass.” I gently glide the ultrasound probe over his mid-abdomen to find a 12-cm wide aorta filled with clot.  Six units of typed and crossed blood are called for as two units of O-negative blood are given via a pressure infuser. The vascular surgery team assembles, and my patient is whisked off to the operating room.

Days have passed. My patient is discharged from the hospital with his health intact.  I continue working shifts in the ED, managing mundane illnesses along with critical life or death situations every day.

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