Madtown Sono

Middle-aged male with chest pain

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By Hani Kuttab, MD

Clinical Case

A middle-aged male presented to the Emergency Department with complaints of chest congestion and cough for the past several weeks. He had recently completed a course of oral antibiotics for suspected pneumonia without improvement. Vital signs were significant for a heart rate of 115, blood pressure of 108/76. The patient had an oxygen saturation 98%. Chest X-Ray demonstrated cardiomegaly with hilar lymphadenopathy of unknown significance. Given this, a bedside echocardiogram was performed:

Bedside echocardiogram with parasternal, subxiphoid, and apical 4-chamber views
Figure 1. Bedside echocardiogram with parasternal, subxiphoid, and apical 4-chamber views

Diagnosis

Pericardial Effusion with Cardiac Tamponade. Bedside ultrasound revealed a large pericardial effusion with concern for pericardial tamponade. Characteristic findings of tamponade include 1) pericardial effusion, 2) diastolic right ventricular collapse (high specificity), 3) systolic right atrial collapse (earliest sign), 4) plethoric interior vena cava (IVC) with minimal respiratory variation, and 5) exaggerated respiratory cycle changes in mitral and tricuspid valve in-flow velocities (surrogate for pulses paradoxus) (Figure 2) (1). Emergency medicine physicians must recognize and understand these findings to secure this diagnosis and alter patient management.

In regard to pericardial effusions, the rate of fluid accumulation is more important than the actual effusion size. Beware of false positives, such as a pleural effusion (which tracks lateral to the descending aorta) or a pericardial fat pad (which has a more “stippled appearance” and appears to move in concert with the myocardium (1). Also, don’t forget to use M-mode when evaluating for RV collapse during diastole, defined as the opening of the mitral valve,

Our patient was emergently taken for a pericardial window with interventional cardiology. Pathology revealed a malignant effusion, and the patient was later found to have a new diagnosis of metastatic lung adenocarcinoma.

Five key findings of pericardial tamponade
Figure 2. Five key findings of pericardial tamponade (1). Know these!

Teaching Point

Know the sonographic features of cardiac tamponade and use your adjunct tools (i.e. IVC, M-Mode) to secure this diagnosis.

References

  1. Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade?. Am J Emerg Med. 2019;37(2):321-326. doi:10.1016/j.ajem.2018.11.004.