Saved by point of care echo

1. PATIENT PRESENTATION

A 40‐year‐old black male with a past medical history of sickle cell disease, cardiomyopathy, and pulmonary hypertension presents as a transfer from an outside facility to a tertiary care hospital for evaluation after a formal echocardiogram reported “biatrial enlargement and small cystic structure adjacent to the right atrium.”

The patient arrived at the receiving hospital in acute severe distress with altered mental status, tachycardia, tachypnea, hypoxia, and hypotension with near agonal respirations on bilevel positive airway pressure. He was also noted to have bilateral jugular venous distention to the angle of mandibles and bilateral lower extremity edema. Given the acuity of the patient's condition, a bedside point‐of‐care (POC) ultrasound was done using the Rapid Ultrasound for Shock and Hypotension (RUSH) protocol.

Bilateral lung slide was present with a bilateral A‐line profile. Inferior vena cava (IVC) interrogation showed a markedly dilated non‐distensible IVC. In the apical 4‐chamber cardiac view, with color Doppler, it became obvious that there was a very large extracardiac cystic mass nearly completely compressing the right atrium (Video 1). Mitral valve inflow velocity was assessed via pulse wave Doppler and was found to demonstrate echocardiographic pulsus paradoxus (Figure 1). The emergency physician made the diagnosis of an extracardiac cystic mass compressing the right atrium causing pericardial tamponade rapidly at the bedside. A multidisciplinary team was mobilized by the emergency physician and the epicardial cyst was drained under ultrasound guidance in the emergency department resulting in 1300 cc of serous fluid with the restoration of the right atrium volume, normalization of the patient's vital signs, and return to his normal mental status.

VIDEO 1.

Apical 4 chamber view with a large extracardiac cyst masquerading as right atrial dilation. The true and compressed right atria can be seen as the origin for the color jet near the automated implantable cardioverter defibrillator lead.

FIGURE 1.

Pulsed wave Doppler of the mitral inflow velocity demonstrating echocardiographic pulsus paradoxus with greater than 25% peak mitral valve inflow velocity drop with respiration.

2. DIAGNOSIS

2.1. Pericardial tamponade

Pericardial tamponade occurs when there is an impairment of ventricular filling due to atrial compression by pericardial fluid or blood. ¹ Far more rarely, cardiac tamponade can be caused by extrinsic compression. ² Traumatic pericardial effusions typically occur rapidly and present as acute hemodynamic compromise in the setting of trauma. Medical causes of tamponade can be much more insidious given the usually slower accumulation of pericardial fluid. Pericardial tamponade presents typically as either cardiogenic or obstructive shock. Although physical exam findings such as Beck's triad, are often cited, echocardiography provides an invaluable tool in the detection of tamponade. ³ In one case series, the sensitivity of the presence of all 3 components of Becks Triad was 0%, whereas any single element had a sensitivity 50%. ⁴ Emergency physicians can rapidly diagnose pericardial tamponade with POC ultrasound and thus render lifesaving treatment, as in this case.

Byars D, Feyzeau K, Jones M, Landon JD, Knapp B. Saved by point of care echo. JACEP Open. 2023;4:e12911. 10.1002/emp2.12911