Answer 4

This is a TG SAX view of the mid-papillary level of the LV. It shows a dilated LV, with globally very severely impaired LV function. (The markers down the side of the ECHO image are at 1 cm intervals. The normal LV end-diastolic diameter for men is up to 5.9cm¹, and this is roughly >6.5cm. (Also, this measurement should be indexed to body surface area, so if he is not a large man this is more abnormal.) There is little change between the end-diastolic area (EDA), and the end-systolic area (ESA), so the fractional area of change is going to be very low, consistent with very low ejection fraction.

Using a high-dose vasopressor in this situation will decrease the cardiac output, as the heart cannot preserve stroke volume against the raised SVR. This is likely why peripheral perfusion is poor and why there is a metabolic acidemia. The ideal treatment in a patient with very poor systolic function is an inodilator, (for example dobutamine), as it increases inotropy and decreases afterload, thus increasing cardiac output. However, in this instance you are struggling with hypotension, so an inotrope such as epinephrine that won’t drop the SVR is more appropriate in the acute setting. If the MAP is not sufficient with this alone then a lower dose of vasopressor could be added. Cardiac function is also depressed by acidemia, so increasing the ventilation to try and normalize pH would also be useful, +/- sodium bicarbonate if pH does not improve in a timely fashion with better cardiac output.