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A Woman in Her 70s Presented to the ED Complaining of Worsening Shortness of BreathAn Elderly Woman Has Worsening Shortness of Breath FREE TO VIEW

Jennifer V. Huang, DO; Amy Sanghvi, MD; James W. Tsung, MD, MPH; Bret P. Nelson, MD, RDMS
Author and Funding Information

From the Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.

CORRESPONDENCE TO: Jennifer V. Huang, DO, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1149, New York, NY 10029; e-mail: jennifer.huang@mssm.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):e195-e197. doi:10.1378/chest.14-0265
Text Size: A A A
Published online

A woman in her 70s with a past medical history of diabetes, hypertension, end-stage renal disease, cirrhosis, obesity, congestive heart failure, and pulmonary embolism (PE) on warfarin presented to the ED with a complaint of 2 days of worsening shortness of breath. While en route to the hospital, she told her family that it was getting more difficult for her to breath, and she became unresponsive in her vehicle outside of the ED. She was found to be in pulseless electrical activity. CPR was immediately initiated, and return of spontaneous circulation occurred after several minutes of CPR. During the resuscitation, the patient was intubated and had large amounts of pink frothy sputum; emergent central venous and arterial catheters were placed. A focused cardiac ultrasound was performed (Video 1).

Video 1

Case Presentation

Running Time: 0:57

Based on the interpretation of the video and the patient’s clinical presentation, what is the most likely diagnosis?
Answer: Cardiac tamponade

Cardiac tamponade was suspected to be the cause of the patient’s cardiac arrest because of the large pericardial effusion seen in the parasternal long axis and subxiphoid cardiac views. The plethoric inferior vena cava (IVC) with spontaneous echo contrast and retrograde flow further supported this diagnosis.

Emergent pericardiocentesis was performed using the subxiphoid approach. The needle was advanced until a bloody aspirate was noted. To confirm needle placement, agitated saline was injected (Video 2). The agitated saline and needle tip were visualized within the right ventricle (RV), so the needle was repositioned, agitated saline was reinjected, and both were then noted to be within the pericardial space (Video 2). A catheter was inserted into the pericardium, 700 mL of bloody aspirate was withdrawn, and the patient’s BP and oxygen saturation improved. Repeat cardiac ultrasound demonstrated a significantly smaller effusion.

Video 2

Procedure

Running Time: 1:56

In this case, performing focused cardiac ultrasound at the bedside was crucial to identifying tamponade as the immediate cause of the patient’s arrest. It also provided information that helped the clinician exclude some of the other possible causes of shock. The patient had a history of PE; however, the RV was not significantly larger than the left ventricle, making PE an unlikely cause. The left ventricle in this patient was hypocontractile, however, it was unlikely that heart failure was the primary etiology of the patient’s arrest. The plethoric IVC went against the diagnosis of hypovolemic or hemorrhagic shock. What was most evident on the cardiac views was a large, circumferential pericardial effusion. This finding, in conjunction with the patient’s clinical presentation, prompted the clinician to consider tamponade as the likely diagnosis (Video 3).

Video 3

Discussion

Running Time: 3:10

Other echocardiographic findings that can be seen with tamponade are diastolic collapse of the RV, systolic collapse of the right atrium (RA), or both. These findings are seen as pericardial volume and pressures increase and eventually exceed chamber pressures. The patient in this case had evidence of RA collapse, but did not have diastolic RV collapse. Systolic RA collapse is a highly sensitive sign of tamponade, however, it is not as specific as RV diastolic collapse.1 It should be noted that patients with infiltrative cardiac disease or RV hypertrophy may not display RV collapse. IVC plethora is another highly sensitive (97%), but not very specific, echocardiographic sign of tamponade.1 As pericardial pressures impede venous return, collapse of the IVC during respiration diminishes, resulting in a plethoric IVC. In contrast, a collapsing IVC is generally not seen in patients with tamponade. Because multiple physiologic states can cause a plethoric IVC, the clinical context is central to making the diagnosis of tamponade. In a patient with shock, a circumferential and large effusion, visible both anteriorly and posteriorly, may be the only suggestion of possible tamponade. Given the ranges of sensitivity and specificity of the above-described signs, it is important that the clinician be proficient at evaluating the echocardiographic findings that can be seen with tamponade.

Ultrasound-guided pericardiocentesis has been established as the gold standard because it results in lower complication rates and allows the physician to choose the safest approach.2 There has been no universally agreed upon optimal approach to pericardiocentesis. Approaches include subxiphoid, left parasternal, right parasternal, para-apical, posterolateral, and axillary. In the Tsang et al3 dataset with 1,127 patients, the para-apical approach was used in the majority of cases, with the subxiphoid approach being the next most common approach. In the study by Callahan et al4 of 118 patients, the anterior axillary approach was used most frequently. In the study by Vayre et al,5 109 of 110 pericardiocenteses were performed using the subxiphoid approach. Similarly, in the study by Lindenberger et al,6 248 of 252 patients had a subxiphoid approach.

This variability in practice suggests institutional or provider preference in site selection. Echocardiography textbooks advocate evaluating for pericardial tamponade and guiding the entry point for pericardiocentesis using multiple cardiac views.7 Although physicians have historically been most familiar with the subxiphoid approach, the recommendation is to choose the approach with the shortest trajectory to the effusion, the maximal effusion appearance, and one that avoids vital structures.8 In this case, parasternal cardiac views did not show a drainable anterior fluid pocket. The maximal effusion was posterior and inferior to the heart and the best trajectory was the subxiphoid approach. Additionally, the clinician performing the pericardiocentesis had the most experience with the subxiphoid approach.

The use of agitated saline to confirm proper needle placement prevented inadvertent intraventricular placement of the catheter and was critical to the success of the pericardiocentesis. If the aspirated fluid appears hemorrhagic, the use of contrast in the form of agitated saline to confirm that the fluid aspirated is pericardial, and not the result of myocardial puncture, is recommended.9,10 Though chamber perforation is rare, it can cause life-threatening arrhythmias and/or injuries that require operative intervention.4,6

Post pericardiocentesis, cardiac ultrasound can also be used to evaluate adequate pericardial fluid drainage. Improvement in the patient’s cardiac contractility and hemodynamics should be used to guide how much fluid is drained. A catheter should be left in the pericardial space so that additional fluid can be drained if the patient’s hemodynamic status deteriorates.

Prompt decompression of pericardial tamponade is a life-saving measure. The clinician’s ability to perform and interpret cardiac ultrasound at the bedside was crucial to the successful diagnosis of cardiac tamponade as the cause of this patient’s cardiac arrest. The use of cardiac ultrasound was also critical in guiding pericardiocentesis and correct catheter placement.

  • 1. Clinicians should be skilled in focused cardiac ultrasound and able to evaluate the echocardiographic findings (large pericardial effusion, RA systolic diastolic collapse, RV diastolic, IV fluids plethora) that can be seen with cardiac tamponade.

  • 2. In critically ill patients in shock, a sizeable pericardial effusion on cardiac ultrasound should prompt the clinician to consider tamponade as a potential diagnosis.

  • 3. The approach to pericardiocentesis should be tailored to the characteristics of the patient’s effusion, considering the shortest trajectory, maximal effusion, and avoidance of vital structures.

  • 4. Ultrasound-guided pericardiocentesis should be the standard of care. Ultrasound confirmation of needle placement with agitated saline can prevent inadvertent myocardial puncture.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Nelson is a consultant for Simulab Corporation. Drs Huang, Sanghvi, and Tsung have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Himelman RB, Kircher B, Rockey DC, Schiller NB. Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade. J Am Coll Cardiol. 1988;12(6):1470-1477. [CrossRef] [PubMed]
 
Maisch B, Seferović PM, Ristić AD, et al; Task Force on the Diagnosis and Management of Pricardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25(7):587-610. [CrossRef] [PubMed]
 
Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77(5):429-436. [CrossRef] [PubMed]
 
Callahan JA, Seward JB, Nishimura RA, et al. Two-dimensional echocardiographically guided pericardiocentesis: experience in 117 consecutive patients. Am J Cardiol. 1985;55(4):476-479. [CrossRef] [PubMed]
 
Vayre F, Lardoux H, Pezzano M, Bourdarias J-P, Dubourg O. Subxiphoid pericardiocentesis guided by contrast two-dimensional echocardiography in cardiac tamponade: experience of 110 consecutive patients. Eur J Echocardiogr. 2000;1(1):66-71. [CrossRef] [PubMed]
 
Lindenberger M, Kjellberg M, Karlsson E, Wranne B. Pericardiocentesis guided by 2-D echocardiography: the method of choice for treatment of pericardial effusion. J Intern Med. 2003;253(4):411-417. [CrossRef] [PubMed]
 
Amstrong WF, Ryan T. Feigenbaum’s Echocardiography.7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:241-261.
 
Jung HO. Pericardial effusion and pericardiocentesis: role of echocardiography. Korean Circ J. 2012;42(11):725-734. [CrossRef] [PubMed]
 
Watzinger N, Brussee H, Fruhwald FM, et al. Pericardiocentesis guided by contrast echocardiography. Echocardiography. 1998;15(7):635-640. [CrossRef] [PubMed]
 
Chiang HT, Lin M. Pericardiocentesis guided by two-dimensional contrast echocardiography. Echocardiography. 1993;10(5):465-469. [CrossRef] [PubMed]
 

Figures

Tables

Video 1

Case Presentation

Running Time: 0:57

Video 2

Procedure

Running Time: 1:56

Video 3

Discussion

Running Time: 3:10

References

Himelman RB, Kircher B, Rockey DC, Schiller NB. Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade. J Am Coll Cardiol. 1988;12(6):1470-1477. [CrossRef] [PubMed]
 
Maisch B, Seferović PM, Ristić AD, et al; Task Force on the Diagnosis and Management of Pricardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25(7):587-610. [CrossRef] [PubMed]
 
Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77(5):429-436. [CrossRef] [PubMed]
 
Callahan JA, Seward JB, Nishimura RA, et al. Two-dimensional echocardiographically guided pericardiocentesis: experience in 117 consecutive patients. Am J Cardiol. 1985;55(4):476-479. [CrossRef] [PubMed]
 
Vayre F, Lardoux H, Pezzano M, Bourdarias J-P, Dubourg O. Subxiphoid pericardiocentesis guided by contrast two-dimensional echocardiography in cardiac tamponade: experience of 110 consecutive patients. Eur J Echocardiogr. 2000;1(1):66-71. [CrossRef] [PubMed]
 
Lindenberger M, Kjellberg M, Karlsson E, Wranne B. Pericardiocentesis guided by 2-D echocardiography: the method of choice for treatment of pericardial effusion. J Intern Med. 2003;253(4):411-417. [CrossRef] [PubMed]
 
Amstrong WF, Ryan T. Feigenbaum’s Echocardiography.7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:241-261.
 
Jung HO. Pericardial effusion and pericardiocentesis: role of echocardiography. Korean Circ J. 2012;42(11):725-734. [CrossRef] [PubMed]
 
Watzinger N, Brussee H, Fruhwald FM, et al. Pericardiocentesis guided by contrast echocardiography. Echocardiography. 1998;15(7):635-640. [CrossRef] [PubMed]
 
Chiang HT, Lin M. Pericardiocentesis guided by two-dimensional contrast echocardiography. Echocardiography. 1993;10(5):465-469. [CrossRef] [PubMed]
 
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