62-Year-Old Woman With Acute Hypotension and Hypoxia After Surgical Repair of Hip

Abstract

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN (C.T.L., Y.N.R.); Advisor to residents and Consultant in Cardiovascular Diseases, Mayo Clinic, Rochester, MN (C.R.B.). A 62-year-old woman presented to the emergency department after a mechanical fall onto her left hip. She had been in her usual state of health earlier that day, but after the fall she experienced intractable leg pain and was unable to bear weight on her left hip. She reported no chest pain, dyspnea, palpitations, light-headedness, or dizziness before the event. Her medical history was notable for hypertension and nicotine and alcohol dependence. Her initial physical examination revealed evidence of severe left hip tenderness and pain with motion. The remainder of her examination findings were unremarkable. Radiography of the left hip revealed a left intertrochanteric hip fracture with minimal displacement. She underwent prompt surgical repair with internal fixation using a cephalomedullary nail. The patient tolerated the procedure well with no complications and minimal blood loss. Postoperatively, she received deep venous thrombosis prophylaxis with subcutaneous heparin. Her pain subsided considerably after the operation. At 36 hours postoperatively, the patient experienced sudden shortness of breath with severe respiratory distress. On examination, she was somnolent and had a blood pressure of 90/54 mm Hg and a heart rate of 131 beats/min. She was tachypneic (respiratory rate, 20 breaths/min) and hypoxic (oxygen saturation, 90% with a face mask delivering 40% fraction of inspired oxygen). The patient was afebrile and drowsy but was able to follow commands. Cardiac examination revealed a right ventricular (RV) precordial heave, elevated jugular venous pressure, and cool extremities with a weakly palpable pulse. Auscultation identified a right-sided third heart sound but no murmurs. Lung examination revealed diffuse bilateral crackles but no decreased breath sounds at the base or dullness to percussion suggestive of a pleural effusion. She had bilateral mild pitting edema on the lower