1p/cc HPL PE Labs Imaging Gross Pathology Treatment Discussion A.29-yearold male comes to the medical clinic because of palpitations, weakness, and fatigue that docs not allow him to walk more than five blocks, together with coldness of his right foot, He underwent surgery 4 weeks ago for a penetrating stab-wound injury in his right groin that he sustained during a fight. ‘VS: marked tachycardia. PE: continuous murmur and casily palpable thrill over area of wound; skin over wound warm to touch; right foot cold to touch with diminished pulse; tachycardia diminished when pressure applied to site of fistula (BRaNHAM’s SIGN). CBC/Lytes: normal. LFTs, glucose, BUN, creatinine normal MR/Angio: large AV connection (fistula) in groin area with significant diversion of blood flow. US: color flow Doppler shows rainbow-colored turbulence in fistula; high-velocity and arterial- ized (pulsatile) waveform in draining ve Abnormal communication between artery and vein, in this case asa result of a penetrating injury. Surgical repair if symptomatic and large; angiographic embolization if smaller. Ultrasound guided direct compression is sometimes an option. Arteriovenous fistula may clinically present as high-output cardiac failure. Iatrogenic AV fistulas may be seen after arteriography. ARTERIOVENOUS FISTULA ADOTOINYVIjcc HPL PE Labs Imaging Gross Pathology Treatment Discussion Atlas Link A 42-year-old female presents with progressive shortness of breath on exertion and palpitations. The patient has been symptom free until now. VS: irregular left parasternal heave; grade II/VI systolic ejection flow murmur in left second intercostal space; widely split, fixed $2 (does not change with breathing). egular pulse. PI ECG; atrial fibrillation; RSR pattern in right precordial leads; rightaxis deviation (right ventricular hypertrophy) CXR: dilated proximal pulmonary arteries; increased pulmonary icle; small aor- ight flow. vascularity; enlarged right atrium and right ve tic knob. Echo: paradoxical septal movement; left-c Cardiac catheterization confirmatory. ‘The most common form is in the midseptum, in the area of the foramen ovale (ostiUM SECUNDUM); those in the lower septum (ostUuM PRiMUs) are associated with AV valve anomalies (most common in Down's); those in the upper septum (stNUS VENosUs) are associated with anomalous pulmonary venous return. Surgical or interventional angiographic closure of defect with prosthetic patch. Operative repair is recommended in all symp- tomatic patients with ostium secundum defects regardless of si of defect. Oxygenated blood from the left atrium passes into the right atrium, increasing right ventricular output and pulmonary flow: Acyanotic (left-to-right shunt); the most common congenital heart disease in adults. Sequelae of untreated atrial septal defects include paradoxie emboli, infective endocarditis, and congestive heart failure. (ICI) PG-A-002 [EA ATRIAL SEPTAL DEFECTIp/cc HPL PE Labs Imaging Gross Pathology Treatment Discussion A. 25-year-old male postal worker who was stabbed in the chest during a mugging is brought to the emergency room in a semi- conscious state, gasping for air (DYSPNEA) ‘The knife penetrated the thoracic wall at the level of the fourth intercostal space along the left sternal border. VS: hypotension (BP 90/40) that does not respond to rehydra- tion; inspiratory lowering of systolic BP by > 10 mmHg (rutsus PaRADOXUS). PE: increase in venous pressure with inspi filling of neck veins during inspiration (KussMati’s stGN); during drawing of venous blood, syringe filled spontaneously (due to increased venous pressure); apical impulse diminished; heart sounds seem distant; patient also cyanotic. ECG: reduced voltage. CXR: cardiomegaly, but with acute hemopericardium, the heart shadow may not enlarge; thus diagnosis is clinical. Echo: pericardial fluid; diastolic collapse of right ventricle and atria. Blood from sites of injury fills pericardial sac, causing compres- sion of all heart chambers and preventing venous return, heart filling, and arterial outflow. Immediate pericardiocentesis and subsequent operative thora- cotomy and pericardial decompression with repair of laceration, Unlike this case, the majority of patients with penetrating chest trauma will have a pneumothorax or hemothorax. The triad of Beck (hypotension, distant heart sounds, and increased venous pressure) is characteristic of cardiac tamponade. CARDIAC TAMPONADE ADOTOICYV)