Presentation
Past medical history significant for end stage renal disease, presents with lethargy and somnolence x 3 days. VS on arrival are BP 96/42, HR 94, RR 22, T 37.1, 96% on RA. JVD to angle of mandible w/ + kussmaul sign and bibasilar rales on physical exam.
Patient Data
Cine loop 1: linear transducer placed in longitudinal orientation at the right mid-clavicular line, 3rd intercostal space. + lung sliding
Cine loop 2: linear transducer placed in longitudinal orientation at the left mid-clavicular line, 3rd intercostal space. + lung sliding
Cine loop 3: parasternal long axis view. Left ventricle hyperdynamic. Large circumferential pericardial effusion, completely anechoic. Subtle inward deflection of right ventricular free wall in mid-diastole, swinging heart.
Cine loop 4: apical 4 chamber view. Left ventricle hyperdynamic. large effusion re-demonstrated. right atrial systolic inversion.
Case Discussion
A focused cardiac ultrasound study is indicated in the setting of undifferentiated hypotension to assess for the presence or absence of the following entities 1:
- pericardial effusion
- left ventricular systolic dysfunction
- right ventricular dysfunction
- intravascular hypovolemia
Point of care ultrasonography is sensitive for the presence of pericardial fluid, and when present, several features are suggestive of tamponade physiology, including 2:
- right ventricular diastolic collapse
- right atrial systolic inversion
- plethoric, invariant inferior vena cava
Pericardial tamponade is, however, ultimately a clinical diagnosis. This patient was hypotensive on arrival with JVD on physical exam and echocardiographic evidence of tamponade physiology. Emergency pericardiocentesis was performed, 50mL of fluid removed with subsequent improvement in BP and mental status, and surgery consulted for a pericardial window.
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