Case 4 - Obstructive Shock - Pericardial Tamponade
Indication:
Is a Pericardial Effusion Present: Given the recent cardiac procedure and the low voltages on ECG, the concern was for a pericardial effusion that may result in pericardial tamponade physiology.
Despite the fact the patient had normal blood pressure, the progressive presyncope was concerning as a sign of end-organ hypoperfusion especially the patient had no known history of hypertension.
Is a Pericardial Effusion Present: Given the recent cardiac procedure and the low voltages on ECG, the concern was for a pericardial effusion that may result in pericardial tamponade physiology.
Despite the fact the patient had normal blood pressure, the progressive presyncope was concerning as a sign of end-organ hypoperfusion especially the patient had no known history of hypertension.
Image Acquisition:
Echocardiographic signs suggestive of tamponade was not acquired for several reasons:
(a) Obtaining and maintaining a decent were difficult as the patient was unable to stay still
(b) The clinical information was sufficient to indicate the patient was in tamponade. Additional echocardiographic findings will not change management -- but only consume resources.
(c) The indication for performing the PoCUS in the first place to verify if a pericardial effusion was present.
Interpretation:
The PoCUS findings revealed a pericardial effusion of moderate-large size. The IVC was not collapsing despite the patient was working very hard to breath which indicates the intra-IVC pressure was quite high. As such the hyperdyanmic LV likely reflected significant LV filling.
The IVC collapsibility interpretation in the context of pericardial effusions is important especially when assessing a patient who is in shock. Suppose that the IVC is unequivocally collapsing, the hypovolemia needs to be addressed first. Once volume expanded, the RA and RV pressure may suffice to overcome the intra-pericardial pressure. However, it maybe that even with volume expansion, the increase in RA and RV pressure remains lacking.
Clinical Synthesis:
Given the findings, the diagnosis was cardiac tamponade.
Pulsus paradoxus via blood pressure cuff was not possible with this patient as he was unable to stay still. However, a palpable radial pulsus paradoxus was noted.
Echocardiographic signs suggestive of tamponade was not acquired for several reasons:
(a) Obtaining and maintaining a decent were difficult as the patient was unable to stay still
(b) The clinical information was sufficient to indicate the patient was in tamponade. Additional echocardiographic findings will not change management -- but only consume resources.
(c) The indication for performing the PoCUS in the first place to verify if a pericardial effusion was present.
Interpretation:
The PoCUS findings revealed a pericardial effusion of moderate-large size. The IVC was not collapsing despite the patient was working very hard to breath which indicates the intra-IVC pressure was quite high. As such the hyperdyanmic LV likely reflected significant LV filling.
The IVC collapsibility interpretation in the context of pericardial effusions is important especially when assessing a patient who is in shock. Suppose that the IVC is unequivocally collapsing, the hypovolemia needs to be addressed first. Once volume expanded, the RA and RV pressure may suffice to overcome the intra-pericardial pressure. However, it maybe that even with volume expansion, the increase in RA and RV pressure remains lacking.
Clinical Synthesis:
Given the findings, the diagnosis was cardiac tamponade.
Pulsus paradoxus via blood pressure cuff was not possible with this patient as he was unable to stay still. However, a palpable radial pulsus paradoxus was noted.