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A 53-year-old man is brought to the emergency department after being involved in a

motor vehicle accident as an unrestrained driver. He was found unresponsive at the
scene and was intubated by paramedics. The patient's blood pressure in the emergency
department is 70/30 mm Hg and pulse is 100/min. On physical examination, he responds
to strong vocal and tactile stimuli by opening his eyes. The patient's pupils are equal and
reactive to light. On examination, there are multiple bruises over the anterior chest and
upper abdomen. The trachea is midline. A Swan-Ganz catheter shows a pulmonary
capillary wedge pressure of 14 mm Hg (normal 2-14 mm Hg). Rapid infusion of one liter
of normal saline increases the pulmonary capillary wedge pressure to 22 mm Hg, with a
systemic blood pressure of 75/30 mm Hg and pulse of 123/min. Which of the following is
the most likely diagnosis?

o A Anaphylaxis
o B. Hypovolemia
o C. Myocardial contusion
0 D. Pneumothorax
o E. Pulmonary embolism

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Item ~\='Mark <? [> ai ~ ~ , GJIIA)
O.ld : 4541 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 53-year-old man is brought to the emergency department after being involved in a

motor vehicle accident as an unrestrained driver. He was found unresponsive at the
scene and was intubated by paramedics. The patient's blood pressure in the emergency
department is 70/30 mm Hg and pulse is 100/min. On physical examination, he responds
to strong vocal and tactile stimuli by opening his eyes. The patient's pupils are equal and
reactive to light. On examination, there are multiple bruises over the anterior chest and
upper abdomen. The trachea is midline. A Swan-Ganz catheter shows a pulmonary
capillary wedge pressure of 14 mm Hg (normal 2-14 mm Hg). Rapid infusion of one liter
of normal saline increases the pulmonary capillary wedge pressure to 22 mm Hg, with a
systemic blood pressure of 75/30 mm Hg and pulse of 123/min. Which of the following is
the most likely diagnosis?

A Anaphylaxis [1%]
B. Hypovolemia [1 2%]
., C. Myocardial contusion [76%]
D. Pneumothorax [7%]
'.J E. Pulmonary embolism [4%)

- .. '
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Explanation: User ld

Hemodynamic measurements in shock

Hypovolemic Cardiogenic Septic

Parameter Normal
shock shock shock

Right atrial Normal

pressure Mean of 4 mm Hg I I to slight 1
(preload)

Pulmonary
capillary wedge Normal
Mean of 9 mm Hg I I
pressure to slight I
(preload)

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Explanation: User ld

Hemodynamic measurements in shock

Hypovolemic Cardiogenic Septic

Parameter Normal
shock shock shock

Right atrial Normal

pressure Mean of 4 mm Hg I I to slight I
(preload)

Pulmonary
capillary wedge Normal
Mean of 9 mm Hg I I
pressure to slight I
(preload)

Cardiac index 2.8-4.2 Umin/m2

(pump function) I II I

Systemic
vascular Mean of 1,150
resistance dynes. seclcrrf I I I
(afterload)

Mixed venous
oxygen 60%-80% I I I
saturation
©UWortd

This patient's clinical presentation is consistent with shock following a motor vehicle
accident (MVA). The pulmonary capillary wedge pressure (PCWP) is slightly
elevated at baseline and increases significantly after infusion of saline without an
appreciable change in systemic blood pressure. This is suggestive of elevated
intracardiac filling pressures due to left ventricular dysfunction, which is most likely
caused by myocardial contusion (injury to the myocardium) sustained during the
accident.
Myocardial contusion is in the spectrum of potential cardiac injuries caused by blunt

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Item ~\='Mark <? [> at ~ ~ , GJIIA)
0. ld: 4541 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

oxygen 60%-80% I I t
saturation
@UWorld

This patient's clinical presentation is consistent with shock following a motor vehicle
accident (MVA). The pulmonary capillary wedge pressure (PCWP) is slightly
elevated at baseline and increases significantly after infusion of saline without an
appreciable change in systemic blood pressure. This is suggestive of elevated
intracardiac filling pressures due to left ventricular dysfunction, which is most likely
caused by myocardial contusion (injury to the myocardium) sustained during the
accident.
Myocardial contusion is in the spectrum of potential cardiac injuries caused by blunt
trauma to the chest, which also may include asymptomatic cardiac arrhythmias; valvular,
septal, or ventricular wall injuries; ventricular free wall rupture; pericardia! tamponade;
and death. An urgent echocardiogram should be obtained in patients with blunt chest
trauma and signs of acute heart failure or shock.
(Choice A) Anaphylaxis is a type of distributive (or vasodilatory) shock due to severely
decreased systemic vascular resistance. The PCWP in patients with anaphylaxis is
typically low or normal and improves slightly toward normal with aggressive fluid
resuscitation.
(Choice B) All patients with hypotension after an MVA should be presumed to have
hypovolemic shock from hemorrhage. Patients with hypovolemic shock typically have a
decreased PCWP at baseline that improves toward normal with saline infusion.

(Choice D) Tension pneumothorax after an MVA can clinically present with hypotension
and shock due to direct extracardiac compression of the left and/or right ventricles.
PCWP is usually low or normal and changes only slightly with saline infusion. Tension
pneumothorax also causes deviation of the trachea to the opposite side.
(Choice E) Massive pulmonary embolism after an MVA (air or fat embolism) can lead to
hypotension/shock; however, the PCWP would be expected to be low or normal at
baseline and minimally change toward normal with saline infusion.
Educational objective:
All patients with hypotension/shock after a motor vehicle accident should be presumed to
have hypovolemic shock from hemorrhage. An elevated pulmonary capillary wedge
pressure at baseline should raise the suspicion of myocardial dysfunction due to cardiac
contusion and prompt an urgent echocardiogram.

References:

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Item ~\='Mark <? [> at ~ ~ , GJIIA)
0. ld: 4541 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

This patient's clinical presentation is consistent with shock following a motor vehicle
accident (MVA). The pulmonary capillary wedge pressure (PCWP) is slightly
elevated at baseline and increases significantly after infusion of saline without an
appreciable change in systemic blood pressure. This is suggestive of elevated
intracardiac filling pressures due to left ventricular dysfunction, which is most likely
caused by myocardial contusion (injury to the myocardium) sustained during the
accident.
Myocardial contusion is in the spectrum of potential cardiac injuries caused by blunt
trauma to the chest, which also may include asymptomatic cardiac arrhythmias; valvular,
septal, or ventricular wall injuries; ventricular free wall rupture; pericardia! tamponade;
and death. An urgent echocardiogram should be obtained in patients with blunt chest
trauma and signs of acute heart failure or shock.
(Choice A) Anaphylaxis is a type of distributive (or vasodilatory) shock due to severely
decreased systemic vascular resistance. The PCWP in patients with anaphylaxis is
typically low or normal and improves slightly toward normal with aggressive fluid
resuscitation.
(Choice B) All patients with hypotension after an MVA should be presumed to have
hypovolemic shock from hemorrhage. Patients with hypovolemic shock typically have a
decreased PCWP at baseline that improves toward normal with saline infusion.

(Choice 0) Tension pneumothorax after an MVA can clinically present with hypotension
and shock due to direct extracardiac compression of the left and/or right ventricles.
PCWP is usually low or normal and changes only slightly with saline infusion. Tension
pneumothorax also causes deviation of the trachea to the opposite side.
(Choice E) Massive pulmonary embolism after an MVA (air or fat embolism) can lead to
hypotension/shock; however, the PCWP would be expected to be low or normal at
baseline and minimally change toward normal with saline infusion.

Educational objective:
All patients with hypotension/shock after a motor vehicle accident should be presumed to
have hypovolemic shock from hemorrhage. An elevated pulmonary capillary wedge
pressure at baseline should raise the suspicion of myocardial dysfunction due to cardiac
contusion and prompt an urgent echocardiogram.

References:
1. Blunt cardiac injury.

Time Spent: 2 seconds Copyright © UWorld Last updated: [11 /04/2016]

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