Introduction: Profound investigation of clinical, laboratory and imaging findings is crucial for optimal management of shock. (1) We here present a post-resuscitation patient in hypertensive pulmonary edema that presented as shock.

Case report: 66-year-old male was successfully resuscitated for cardiac arrest with pulseless electrical activity in the Emergency department. A posteriori heteroanamnestic data suggested dyspnea on exertion and several episodes of syncope in preceding months. History of heavy smoking and hypertension was also known. As consistent hypotension was measured (60/30 mmHg) noradrenalin was started at escalating rate until 1.0 mcg/kg/min. Initial work-up revealed diffuse pulmonary infiltrates resembling cardiac or non-cardiac edema. Upon admission to cardiac intensive care unit, adequate pulsations of right femoral artery were detected. Invasive blood pressure monitoring at this site provided normotensive pressures, and lactate levels measured 1.6 mmol/L. However, mechanical ventilation required high positive end expiratory pressures and weaning trials failed. Echocardiography revealed marked left ventricle hypertrophy and imaging of aorta suggested Leriche syndrome with stenoses/occlusions of all 3 supra-aortic branches. Thus, within catheterization laboratory, a 60 cm sheath was placed into abdominal aorta where blood pressures measured 220/90 mmHg. It was eventually after endovascular procedures assuring adequate limb blood flows that normotension was reached and patient successfully extubated. Clinical course was otherwise unremarkable.

Conclusion: A thorough work-up is needed in all cardiac arrest patients, but particularly meticulous inspection is needed in patients with seemingly persistent shock.