(P15) A Case for Early ED POCUS for Undifferentiated Dyspnea

Chief Complaint : Shortness of Breath

History of Present Illness : 88-year old male with a past medical history of ESRD, ICM(EF of 55%), CAD, atrial fibrillation on apixaban, and gastric malignancy s/p billroth II surgery, and a recent admission one week ago for pneumonia now presenting with progressively worsening shortness of breath over one week. Since discharge from the hospital, he reports dyspnea on exertion and decreased exercise tolerance, which is now limited to walking one block. Now he reports significant impairment to daily activities, stating he cannot even bathe himself or get dressed without feeling winded and needing to stop and rest. Reports mid-sternal chest tightness, 4/10 that was not worse with exercise, inspiration, and not relieved with over the counter medications. Denies fevers, chills, coughing, GU or GI symptoms.

Pertinent Physical Exam: Patient presented in acute respiratory distress. Vital signs notable for hypoxia with SpO2 88% on RA, tachypnea (RR 26-30). He was subsequently placed on BiPAP with oxygen improvement to 100%. Otherwise, the patient was afebrile, not tachycardic (HR 64), and initially normotensive (BP 138/75). Remaining exam notable for JVD and no pedal edema. Cardiac POCUS performed, revealing a massive septated pericardial effusion, some views concerning for tamponade physiology including RV diastolic collapse and plethoric IVC. The patient became hypotensive with MAP 50-60. Given concerns for obstructive shock and tamponade physiology, Levophed was started and cardiology was called emergently.

Pertinent Laboratory Data: Labs: INR 2.0, Cr 10.8 (but on HD), Trop 0.04, Lactate 2.7, Hgb 7.4 (down from a baseline of 9.0 7 days ago), BNP 1268
Consults: CCM and CT Surgery consulted for respiratory distress and POCUS showing large Pericardial effusion with RV collapse. Recommended IV fluids and emergent pericardiocentesis. He went to the cath lab where 750 cc of sanguineous fluid was drained with 3900 WBC, >3 million RBC and normal glucose, LDH and protein.
Medications: Levophed was started for tamponade physiology. Given vitamin K and K centra to reverse coagulopathy

Case Discussion: Pericardial effusion is considered to be present when the fluid within the pericardium exceeds the small amount that is usually present. Pericardial effusions can occur as a component of almost any pericardial disease including infectious, idiopathic, autoimmune, malignancy, trauma, pericardial injury syndromes, metabolic, and aortic diseases.

The management of a pericardial effusions is dependent on the classification and hemodynamic impact of the effusion. Cardiac tamponade occurs when the intrapericardial pressure exceeds the intracardiac pressures. Classically, the clinical manifestations of tamponade in the acute setting are hypotension, elevated systemic venous pressure, and muffled heart sounds. In the sub-acute setting hypotension may not always be present. Other signs and symptoms of cardiac tamponade include dyspnea, tachycardia, and pulsus paradoxus.

Point of care ultrasound (POCUS) provides a great adjunct tool for the diagnosis of tamponade. The major ultrasonographic findings of tamponade include pericardial effusion, systolic right atrial collapse, diastolic right ventricular collapse, and IVC dilation with < 50% reduction in diameter with respiratory phases.

Early cardiac POCUS prior to the onset of hypotension in this case was essential to the diagnosis and timely management of this patient. Unique to this patient was the presence of a septated/loculated pericardial effusion compressing the RA/RV. RV diastolic collapse was noted as a concern given the compressed appearance of the RV but it was questionable. The clinicians correctly recognized that the POCUS findings given the patient’s whole clinical presentation warranted emergent pericardiocentesis. Formal echocardiogram done prior to pericardiocentesis in the cath lab reported no presence of RV diastolic collapse.

A learning point of this case is that septated/loculated effusions can lead to regional tamponade in which only selected chambers are compressed. As a result the echocardiographic signs and hemodynamics of regional cardiac tamponade may differ from standard circumferential pericardial effusions.

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