Syncope and Sweat in a 65-Year-Old Man

A 65-year-old man with a history of hypertension was brought to the emergency department by ambulance for a syncopal episode that occurred at a restaurant. His initial blood pressure was in the low 80s but improved to 105/80 after a 500 mL IV saline bolus. His only complaint other than feeling generally weak was being “sweaty.” He denied any injury, pain, fever, vomiting, melena, or shortness of breath and said he had been fine all day until he suddenly got sweaty and passed out.

On exam, the patient was diaphoretic but afebrile with a pulse of 98, a BP of 86/51, a respiratory rate of 20, and a pulse-ox of 95% on room air. Head and neck exam were normal except for mild jugular venous distention (JVD). The patient had normal heart and lung sounds and no abdominal tenders or leg edema.

The initial EKG showed a normal sinus rhythm at 92 with very slight ST depression in the lateral leads. A portable chest x-ray, shown below, was read by the radiologist as normal.

The patient’s BP continued to drop, and he became more diaphoretic. This time his vital signs did not respond to fluids. A bedside ultrasound was done to evaluate for hypovolemia, massive pulmonary embolism, or cardiac tamponade but showed only a small pericardial effusion. A norepinephrine drip was started for fluid refractory hypotension.

Questions 1 & 2: Do you agree with the radiologist’s read of the chest x-ray?  What should be your next test?[[{"type":"media","view_mode":"media_crop","fid":"60299","attributes":{"alt":"","class":"media-image","id":"media_crop_1010437708927","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7607","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"border-width: 0px; border-style: solid; margin: 5px; height: 390px; width: 430px;","title":" ","typeof":"foaf:Image"}}]]

Answers 1 & 2: The mediastinum here is actually borderline in width. A CT of the chest should be ordered.

A cut from the CT chest is shown on the next page.

What does the CT scan show?  What is the treatment?[[{"type":"media","view_mode":"media_crop","fid":"60301","attributes":{"alt":"","class":"media-image","id":"media_crop_2383746280844","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7608","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 430px; border-width: 0px; border-style: solid; margin: 5px; height: 390px;","title":" ","typeof":"foaf:Image"}}]]

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