Emergency Medicine · Year 3 · from Emergency Medicine

Case 2: Cardiac Ultrasound - Pericardial Effusion with Tamponade

Patient Demographics

• Age: 55 years
• Sex: Female
• Occupation: Office manager

Chief Complaint

"I can't catch my breath and my chest feels tight."

History of Present Illness

A 55-year-old female presents with progressive dyspnea over 2 weeks. She reports feeling "pressure" in her chest and notes she can only breathe comfortably sitting upright. She has had a non-productive cough and low-grade fevers. She has a history of breast cancer treated 2 years ago and recent travel to Asia for work.

Initial Assessment

ESI Level: 2 - Respiratory distress with potential cardiac etiology

First Impression:

• Appearance: Anxious, sitting upright, unable to lie flat
• Work of breathing: Mildly labored
• Circulation: Pale, distended neck veins

Vital Signs:

• Heart rate: 116 bpm
• Blood pressure: 92/78 mmHg (narrow pulse pressure!)
• Respiratory rate: 24 breaths/min
• SpO2: 94% on room air
• Temperature: 37.8C
• GCS: 15

Beck's Triad Assessment

Pulsus Paradoxus:

• BP during inspiration: 78/72
• BP during expiration: 94/78
• Difference: 16 mmHg (>10 = significant)

Primary Survey

Airway: Patent Breathing: Tachypneic, clear lungs (significant - no pulmonary edema despite JVD) Circulation: Tachycardic, hypotensive, JVD, narrow pulse pressure Disability: Alert, anxious Exposure: No peripheral edema, no rashes

Bedside Cardiac Ultrasound

Indication: Suspected pericardial effusion/tamponade

Views Obtained:

1. Subxiphoid Four-Chamber View:

• Large circumferential pericardial effusion
• Right ventricular diastolic collapse (pathognomonic for tamponade)
• Swinging heart (pendulum motion in large effusion)

2. Parasternal Long Axis:

• Confirms large effusion (>2cm throughout)
• RV collapse in diastole visible
• No wall motion abnormalities

3. Parasternal Short Axis:

• Circumferential effusion
• "Swinging" septal motion

4. IVC Assessment:

• IVC dilated (>2.5cm)
• Minimal respiratory variation (<50% collapse)
• Indicates elevated RA pressure

Tamponade Physiology

Echocardiographic Signs of Tamponade:

1. RV diastolic collapse - most specific
2. RA systolic collapse - sensitive but less specific
3. IVC dilation with minimal respiratory variation
4. Respiratory variation in mitral/tricuspid inflow (>25%)
5. Swinging heart

This patient has echocardiographic tamponade

Secondary Survey

SAMPLE History:

• Symptoms: Progressive dyspnea, chest pressure, orthopnea
• Allergies: None
• Medications: Tamoxifen, anastrozole
• PMH: Breast cancer (stage II, treated 2 years ago)
• Last Meal: This morning
• Events: 2-week progressive symptoms, travel to Asia

Differential Diagnosis for Effusion:

• Malignant effusion (breast cancer metastasis) - HIGH CONCERN
• Tuberculous pericarditis (recent travel)
• Viral pericarditis
• Uremic pericarditis
• Autoimmune disease

Management

Immediate Stabilization:

• IV fluid bolus (temporizing measure - increases preload)
• Avoid positive pressure ventilation if possible (decreases preload)
• Prepare for pericardiocentesis

Pericardiocentesis - Indication: Tamponade with hemodynamic compromise

Pericardiocentesis Procedure

Ultrasound-Guided Approach:

Equipment:

• 18g spinal needle or pericardiocentesis kit
• 50mL syringe
• Sterile prep, drape
• Ultrasound with linear or curvilinear probe
• Drainage catheter (Seldinger technique)

Technique:

1. Position patient at 45 degrees (effusion layers inferiorly)
2. Identify largest pocket of fluid (often subxiphoid or apical)
3. Sterile prep
4. Local anesthesia
5. Insert needle under real-time ultrasound guidance
6. Aspirate - straw-colored/bloody fluid
7. Place pigtail catheter over wire (Seldinger)
8. Connect to drainage bag

This Patient:

• Subxiphoid approach used
• 750mL serosanguinous fluid drained initially
• Pigtail catheter left in place
• Immediate improvement in BP (108/72) and symptoms

Fluid Analysis

Pericardial Fluid:

• Bloody/serosanguinous
• LDH elevated (exudative)
• Cytology: Malignant cells present - adenocarcinoma
• AFB and cultures: Pending

Diagnosis: Malignant pericardial effusion with tamponade - metastatic breast cancer

Disposition

Admission:

• Cardiology and oncology consultation
• Pericardial drain continued (200mL/day output)
• CT chest: Multiple pulmonary nodules, mediastinal lymphadenopathy
• Oncology staging workup

Treatment Options for Malignant Effusion:

• Pericardial window (surgical)
• Sclerotherapy via catheter
• Systemic chemotherapy
• Radiation (if localized)

This Patient:

• Pericardial window performed day 3
• Started on systemic therapy
• Discharged day 7 with oncology follow-up

Teaching Points

1. Bedside echo diagnoses tamponade: RV diastolic collapse is specific
2. Clinical + echo findings: Beck's triad may be incomplete; echo confirms
3. IVC assessment: Plethoric IVC with minimal collapse = elevated RA pressure
4. Narrow pulse pressure: Early sign of tamponade
5. Pulsus paradoxus: >10 mmHg drop in SBP with inspiration
6. Ultrasound-guided drainage: Safer than blind approach
7. Malignancy is common cause: Especially lung, breast, lymphoma
8. Temporize with fluids: While preparing for definitive drainage

Clinical Image

Image Description: Parasternal long-axis echocardiographic view demonstrating a large circumferential pericardial effusion (asterisk) with the heart appearing to "swim" in the fluid, and early right ventricular diastolic collapse consistent with cardiac tamponade.

Attribution: Image from Wikimedia Commons, Pericardial effusion echo. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Pericardial_effusion_with_tamponade.gif

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