Does this patient with a pericardial effusion have cardiac tamponade?

Immediate sonography and intervention in blunt chest trauma: A case report

Cardiac tamponade is a leading cause of death in blunt thoracic trauma. Ultrasound improved the recognition of cardiac tamponade and therefore has a vital role in acute critical situations in the Emergency Department and in the Intensive Care Unit. Besides recognition of cardiac tamponade, treatment protocols are important. In trauma patients with hemodynamic stable cardiac tamponade, time should be taken for a proper workup for an explorative sternotomy. In hemodynamic unstable trauma patients, the pericardium should be drained, and fluid resuscitation should be performed followed by emergency sternotomy. In this case report we describe a blunt thoracic trauma victim, a 28-year-old male patient without any medical history. He suffered from the unique combination of a tear in the left atrial appendage and a papillary muscle rupture of the right ventricle because of blunt thoracic trauma. Transthoracic echocardiography revealed massive pericardial effusion with diastolic collapse of the right ventricle in our patient. Due to his hemodynamic situation, the patient was brought into the OR for immediate sternotomy and cardiac repair. The patient made a full recovery, was discharged home, and is back to work. This case report emphasizes the relevance of early recognition and treatment of cardiac tamponade in blunt thoracic trauma victims and suggests a multidisciplinary management strategy.

Tuberculous Pericarditis Presenting as Cardiac Tamponade: Role of Echocardiography

Tuberculous pericarditis, a rare but potentially lethal manifestation of tuberculosis, poses diagnostic and therapeutic challenges in clinical practice. Its nonspecific clinical presentation often mimics other conditions, leading to delayed or missed diagnoses. We report a 25-year-old male with no past medical history, who presented with nonspecific symptoms such as fatigue, weight loss, body aches, and dyspnea. An electrocardiogram showed low voltage QRS complex with electrical alternans, and transthoracic echocardiography (TTE) showed large pericardial effusion with tamponade physiology with right ventricular diastolic collapse, the collapse of the right atrium and the inferior vena cava was dilated with a respiratory variation of less than 50%. The diagnosis of tuberculous pericarditis was made based on clinical presentation, imaging, and laboratory findings, including a positive QuantiFERON-TB gold test and pericardial fluid analysis, despite negative cultures. This case highlights the significance of considering tuberculosis in the differential diagnosis of pericardial effusion and underscores the role of imaging and laboratory investigations in diagnosis. Management of tuberculous pericarditis involves a combination of antituberculous chemotherapy, pericardiocentesis, and corticosteroids. Despite its rarity, tuberculous pericarditis carries a high mortality rate and can present as cardiac tamponade, as illustrated in our case. This underscores the need for high clinical suspicion, especially in high-risk populations, for timely diagnosis and initiation of treatment.

Isolated left ventricular cardiac tamponade diagnosed on point-of-care ultrasound in the emergency department: A case report and brief literature review

In this case report, we describe isolated left ventricular cardiac tamponade, a rare complication of cardiac surgery, diagnosed on point-of-care ultrasound (POCUS) in the emergency department (ED). To our knowledge, this is the first report of such a diagnosis made on ED bedside ultrasound. Our patient was a young adult female with a history of recent mitral valve replacement who presented to the ED with dyspnea and was found to have a large loculated pericardial effusion causing left ventricular diastolic collapse. Rapid diagnosis via POCUS in the ED allowed for expedited definitive treatment by cardiothoracic surgery in the operative room and emphasizes the importance of a standard 5-view cardiac POCUS examination when post-cardiac surgery patients present to the ED.

Cardiac tamponade

Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.

Iatrogenic Cardiac Tamponade Secondary to Central Venous Catheter Placement: A Literature Review

Cardiac tamponade is the fluid accumulation within the pericardial sac that compresses the heart and decreases cardiac output. More than 20% of the cases are surgical or non-surgical iatrogenic causes. Cardiac tamponade has been described as a rare complication of central venous catheter placement with an incidence in adults as low as less than 1% but with significantly high mortality of more than 60%. The purpose of this article is to review the incidence, clinical manifestations, pathophysiology, diagnosis, and management of cardiac tamponade after central venous catheter placement as well as different methods to prevent this fatal complication from occurring.

Tamponnade cardiaque

La tamponnade cardiaque est une urgence vitale. Elle se définit comme une accumulation de liquide dans l’espace intrapéricardique, favorisant une augmentation de la pression intrapéricardique et une altération du remplissage cardiaque. Il s’agit d’une des causes du choc obstructif, et la rapidité d’installation détermine le degré d’instabilité hémodynamique. La morbidité et la mortalité dépendent de la rapidité du diagnostic et de sa prise en charge. Peu fréquemment, l’étiologie est tumorale. Ce type d’étiologie se traduit le plus souvent par des tableaux cliniques d’installation lente et progressive. C’est le cas du sujet qui est présenté dans cet article : un homme de 50 ans sans suivi médical et consommateur d’alcool et de tabac, vivant dans un contexte social difficile. L’issue fatale du cas clinique témoigne de la gravité du tableau de présentation initiale. L’électrocardiogramme peut révéler des signes caractéristiques comme le microvoltage du QRS et l’alternance électrique. La méthode standard pour détecter un épanchement péricardique est l’échocardiographie : le diagnostic de tamponnade cardiaque requiert la présence de collapsus complet du coeur droit et dans les cas plus graves des cavités gauches. Les compétences de l’urgentiste en termes d’échographie permettent un diagnostic plus rapide et précis. Le traitement de la tamponnade cardiaque repose principalement sur le soutien hémodynamique (administration volumique et traitement des éventuels troubles du rythme secondaires) en urgence. Cependant, le traitement définitif reste le drainage du liquide accumulé par péricardiocentèse ou par approche chirurgicale.

Postinfluenza Cardiac Tamponade: A Review of Published Case Reports

Increased vaccination rates and better understanding of influenza virus infection and clinical presentation have improved the disease's overall prognosis. However, influenza can cause life-threatening complications such as cardiac tamponade, which has only been documented in case reports. We searched PubMed/Medline and SCOPUS and EMBASE through December 2021 and identified 25 case reports on echocardiographically confirmed cardiac tamponade in our review of influenza-associated cardiac tamponade. Demographics, clinical presentation, investigations, management, and outcomes were analyzed using descriptive statistics. Among 25 cases reports [19 adults (47.6 ±15.12) and 6 pediatric (10.1 ± 4.5)], 15 (60%) were females and 10 (40%) were male patients. From flu infection to the occurrence of cardiac tamponade, the average duration was 7±8.5 days. Fever (64%), weakness (40%), dyspnea (24%), cough (32%), and chest pain (32%) were the most prevalent symptoms. Hypertension, diabetes, and renal failure were most commonly encountered comorbidities. Sinus tachycardia (11 cases, 44%) and ST-segment elevation (7 cases, 28%) were the most common ECG findings. Fourteen cases (56%) reported complications, the most common being hypotension (24%), cardiac arrest (16%), and acute kidney injury (8%). Mechanical circulatory/respiratory support was required for 14 cases (56%), the most common being intubation (9 cases, 64%). Outcomes included recovery in 88% and death in 3 cases. With improving vaccination rates, pericardial tamponade remains an infrequently encountered complication following influenza virus infection. The complicated cases appear within the first week of diagnosis, of which nearly half suffer from concurrent complications including cardiac arrest or acute kidney injury. Majority of patients recovered with timely diagnoses and therapeutic interventions.

Tamponade: To Be or Not to Be? Using Point-of-Care Ultrasound to Answer the Question

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POCUS is a useful tool in the PACU to evaluate hypotension.

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Absence of echocardiographic features can help rule out cardiac tamponade.

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POCUS can expedite workup of differential diagnoses and guide management.

A nomogram for reduced cardiac function in postoperative acute type A aortic dissection patients with acute kidney injury undergoing continuous renal replacement therapy

Background

This study aimed to develop a nomogram to predict reduced cardiac function for acute kidney injury (AKI) patients who received continuous renal replacement therapy (CRRT) after acute type A aortic dissection (ATAAD) surgery.

Methods

This study was a retrospective analysis. ATAAD patients with preoperative normal ejection fraction (EF) and postoperative AKI with CRRT admitted between January 2014 and November 2021 were included. The reduced cardiac function was defined as EF <50%. The data were analyzed by the univariate and multivariate logistic regression analyses. A diagnostic model was established by a nomogram, and its discriminative performance was validated by the received operating characteristic (ROC) curve and concordance (C) statistic. The calibration of the diagnostic model was tested by calibration curves and the HosmerLemeshow test. The clinical utility was evaluated by the decision curve analysis (DCA).

Result

In total, 208 patients were eligible for analysis, of which 98 patients with reduced cardiac function. The logistic regression analyses showed age ≥60 years old, history of coronary atherosclerotic disease, preoperative pericardial tamponade, and cardiopulmonary bypass time were risk factors for reduced cardiac function, which were further employed in the nomogram. As results, nomogram revealed a high predictive power (C statistic = 0.723, 0.654–0.792; the bootstrap-corrected concordance C statistic = 0.711, the area under the ROC curve = 0.723). The calibration curves showed good consistency between the predicted and the actual probabilities (calibration curve: Brier points = 0.208, Emax = 0.103, Eavg = 0.021; Hosmer-Lemeshow test, P = 0.476). DCA showed that the nomogram could augment net benefits and exhibited a wide range of threshold probabilities in the prediction of EF reduction.

Conclusion

This nomogram is an effective diagnostic model for predicting the reduced cardiac function in postoperative ATAAD patients with AKI undergoing CRRT and can be used to protect postoperative renal functions and facilitate patient-specific care after ATAAD surgery.

Concomitant intravascular and extravascular obstructive shock: a case report of cardiac angiosarcoma presenting with pericardial tamponade

Atraumatic pericardial tamponade and intracardiac masses are both recognized etiologies of acute obstructive shock. Pericardial tamponade, is a cardiovascular emergency commonly considered by emergency physicians and, as a result, evaluation for this process has been incorporated into standardized point of care ultrasound algorithms for assessing hypotension. Obstructive shock secondary to intracardiac tumors is an atypical clinical presentation, and although it is evaluated by the same ultrasound imaging modality, it is generally not considered or evaluated for in the emergency department setting. The concomitant presentation of these two pathologic processes is an extremely rare oncologic emergency. Existing literature on the subject is found in a small number of case reports with nearly no prior descriptions in emergency medicine references. In the right clinical context this unique presentation should be considered and evaluated for in the emergency department via point of care ultrasound modality to help guide in the management of the resulting obstructive shock.

Chronic pericardial effusion: current concepts and emerging trends

INTRODUCTION

Pericardial effusion (PEF) is a common and challenging pericardial syndrome with a variety of clinical manifestations ranging from asymptomatic, incidentally uncovered small PEFs, to life-threatening cardiac tamponade.

AREAS COVERED

: This review focuses on the pathophysiology, epidemiology, etiology, classification, clinical findings, diagnostic work-up, management and outcome of PEFs. Particular emphasis has been given on the most recent evidence concerning the contribution of imaging for the detection, differential diagnosis and evaluation of the hemodynamic impact of PEFs on the diastolic filling of the heart. Moreover, simplified algorithms for PEF triage and management have been included.

EXPERT OPINION

The management of patients with PEFs is mainly based on four parameters namely hemodynamic impact on diastolic function, elevation of inflammatory markers, presence of a specific underlying condition known to be associated with PEF and finally size and duration of the effusion. Novel data have contributed to change our view towards large, asymptomatic, "idiopathic" PEFs and dictated a rather conservative approach in most cases. It is also stressed that there is a compelling need for additional research, which is essential for tailored treatments aiming at the improvement of quality of life and containment of health care costs.

Clinically Ambiguous Hemorrhagic Cardiac Tamponade Associated with Apixaban

Hemorrhagic cardiac tamponade in the setting of direct oral anticoagulants (DOACs) is rare but life-threatening. Presentation in subacute cases can also be nonspecific, which can potentially delay diagnosis. A 60-year-old female with a history of heart failure and chronic obstructive pulmonary disease presented with shortness of breath, chest pain, and cough while on treatment with apixaban after a recent hospitalization for pulmonary embolism. Clinical presentation was consistent with multiple diagnoses, including pneumonia and heart failure exacerbation. However, there were several risk factors for hemopericardium with DOACs such as elevated creatinine, hypertension, elevated international normalized ratio (INR), and concomitant use of medications with similar metabolic pathways as apixaban. In addition, subtle findings on examination such as oximetry paradoxus and electrical alternans were crucial for an early diagnosis and management. In this case, we discuss key characteristics of hemopericardium with DOACs, as well as considerations on its management.

Relapsing Multiple Myeloma Presenting as Cardiac Tamponade and Obstructive Uropathy

Cardiac tamponade is a rare manifestation of relapsing extramedullary multiple myeloma and portends poor prognosis. No cases of cardiac tamponade with co-occurring renal obstruction from plasmacytoma have been reported in the literature, making this case a unique presentation of relapsing multiple myeloma. The presence of known malignancy should not limit our differential diagnosis when evaluating patients with signs of cardiac tamponade.

Associated Pleural and Pericardial Effusions: An Extensive Differential Explored

Concurrent pleural and pericardial effusions are not an unusual finding, but their differential diagnosis remains uncertain. Medline-based review identified an extensive list of infectious, inflammatory, neoplastic, iatrogenic, and myriad other etiologies. A single retrospective study had addressed this presentation. Several principles of a diagnostic workup are suggested, acknowledging that a significant minority of patients may not require a comprehensive workup and remain 'idiopathic'.

The role of point-of-care ultrasound in the diagnosis of pericardial effusion: a single academic center retrospective study

Background

Symptomatic pericardial effusion (PCE) presents with non-specific features and are often missed on the initial physical exam, chest X-ray (CXR), and electrocardiogram (ECG). In extreme cases, misdiagnosis can evolve into decompensated cardiac tamponade, a life-threatening obstructive shock. The purpose of this study is to evaluate the impact of point-of-care ultrasound (POCUS) on the diagnosis and therapeutic intervention of clinically significant PCE.

Methods

In a retrospective chart review, we looked at all patients between 2002 and 2018 at a major Canadian academic hospital who had a pericardiocentesis for clinically significant PCE. We extracted the rate of presenting complaints, physical exam findings, X-ray findings, ECG findings, time-to-diagnosis, and time-to-pericardiocentesis and how these were impacted by POCUS.

Results

The most common presenting symptom was dyspnea (64%) and the average systolic blood pressure (SBP) was 120 mmHg. 86% of people presenting had an effusion > 1 cm, and 89% were circumferential on departmental echocardiogram (ECHO) with 64% having evidence of right atrial systolic collapse and 58% with early diastolic right ventricular collapse. The average time-to-diagnosis with POCUS was 5.9 h compared to > 12 h with other imaging including departmental ECHO. Those who had the PCE identified by POCUS had an average time-to-pericardiocentesis of 28.1 h compared to > 48 h with other diagnostic modalities.

Conclusion

POCUS expedites the diagnosis of symptomatic PCE given its non-specific clinical findings which, in turn, may accelerate the time-to-intervention.

Clinical significance of 12 lead ECG changes in patients undergoing pericardiocentesis for cardiac tamponade

INTRODUCTION

The electrocardiogram (ECG) is one of the initial tests done in patients suspected of having a cardiac Tamponade. Historically the emphasis has been on low QRS voltage and electrical alternans, which lacks specificity and sensitivity respectively. Majority of these studies included patients with pericardial effusions without tamponade. Moreover, the influence of different therapeutic interventions such as pericardiocentesis on ECG variables has not been elucidated.

OBJECTIVE

To determine the clinical significance of 12 lead ECG changes in patients undergoing pericardiocentesis for cardiac tamponade.

METHODS

144 patients underwent Echo guided pericardiocentesis for cardiac tamponade at a tertiary care hospital over a period of 7 years. We compared 19 EKG variables pre and post procedure.

RESULTS

Low voltage was detected in only 31 patients (29%) with 19 (18%) patients having persistent low voltage (p value = 0.0047) after the pericardiocentesis. Electrical alternans was only observed in 25 patients (23%), and persisted in 10 patients (10%) following pericardiocentesis. None of the other EKG variables measured changed reliably post procedure.

CONCLUSION

We found that although electrical alternans and low voltage were associated with cardiac tamponade, none of the ECG variables were highly sensitive or specific for the diagnosis, reproducibly changed after drainage or predicted recurrent effusion post-pericardiocentesis.

Contemporary management of pericardial effusion

Pericardial effusion is a relatively common clinical condition with a variety of clinical manifestations ranging from incidentally discovered asymptomatic cases to life-threatening cardiac tamponade. The etiology encompasses idiopathic cases and forms secondary to different conditions, including autoimmune diseases, malignancies, metabolic disorders, etc. While medical therapy should be offered to patients with elevation of inflammatory markers, in specific forms treatment should be appropriate to the underlying disorder. In cases with hemodynamic compromise pericardial drainage either with pericardiocentesis or pericardial "window" is indicated for therapeutic and diagnostic purposes. In the remainder, factors like comorbidities, size and location of the pericardial effusion will influence the clinical decision making. In asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, according to recent evidence, a conservative approach with watchful waiting seems the most reasonable option. The prognosis of pericardial effusions largely depends on the underlying etiologies. Metastatic spread to the pericardium has an ominous prognosis whereas large to moderate effusions have been often associated with known or newly discovered specific underlying causes. Chronic small idiopathic effusions have an excellent prognosis and do not require specific monitoring. Large chronic idiopathic effusions in clinically stable patients require a 3 to 6-month assessment ideally in a specialized unit.

Cardiac tamponade from anticoagulant-related spontaneous haemopericardium in a patient with ischaemic cardiomyopathy and heart failure

We describe the case of an 86-year-old man with a background of severe left ventricular dysfunction and ischaemic cardiomyopathy who, having been optimised for heart failure therapy in hospital, unexpectedly deteriorated again with hypotension and progressive renal failure over the course of 2 days. Common causes of decompensation were ruled out and a bedside echocardiogram unexpectedly diagnosed new pericardial effusion with tamponade physiology. The patient underwent urgent pericardiocentesis and 890 mL of haemorrhagic fluid was drained. Common causes for haemopericardium were ruled out, and the spontaneous haemopericardium was thought to be related to introduction of rivaroxaban anticoagulation. The patient made a full recovery and was well 2 months following discharge. This case highlights the challenges of diagnosing cardiac tamponade in the presence of more common disorders that share similar non-specific clinical features. In addition, this case adds to growing evidence that therapy with direct oral anticoagulants can be complicated by spontaneous haemopericardium, especially when coadministered with other agents that affect clotting, renal dysfunction and cytochrome P3A5 inhibitors.

Development and validation of a novel prediction score for cardiac tamponade in emergency department patients with pericardial effusion

Aims

Determining which patients with pericardial effusion require urgent intervention can be challenging. We sought to develop a novel, simple risk prediction score for patients with pericardial effusion.

Methods and results

Adult patients admitted through the emergency department (ED) with pericardial effusion were retrospectively evaluated. The overall cohort was divided into a derivation and validation cohort for the generation and validation of a novel risk score using logistic regression. The primary outcome was a pericardial drainage procedure or death attributed to cardiac tamponade within 24 h of ED arrival. Among 195 eligible patients, 102 (52%) experienced the primary outcome. Four variables were selected for the novel score: systolic blood pressure < 100 mmHg (1.5 points), effusion diameter [1–2 cm (0 points), 2–3 cm (1.5 points), >3 cm (2 points)], right ventricular diastolic collapse (2 points), and mitral inflow velocity variation > 25% (1 point). The need for pericardial drainage within 24 h was stratified as low (<2 points), intermediate (2–4 points), or high (≥4 points), which corresponded to risks of 8.1% [95% confidence interval (CI) 3.0–16.8%], 63.8% [95% CI 50.1–76.0%], and 93.7% [95% CI 84.5–98.2%]. The area under the curve of the simplified score was 0.94 for the derivation and 0.91 for the validation cohort.

Conclusion

Among ED patients with pericardial effusion, a four-variable prediction score consisting of systolic blood pressure, effusion diameter, right ventricular collapse, and mitral inflow velocity variation can accurately predict the need for urgent pericardial drainage. Prospective validation of this novel score is warranted.

Oncologic Emergencies: Traditional and Contemporary

The recognition and management of oncologic emergencies are becoming increasingly relevant in the intensive care unit, particularly in the era of novel biologic therapies. Early recognition and multidisciplinary collaboration are essential to improving patient outcomes. This article discusses aspects of diagnosis and management for important malignancy-associated emergencies.

[Delayed tamponade: Four cases of rare complication of blunt chest trauma]

Delayed post-traumatic pericardial effusion is a rare condition after blunt trauma. The diagnosis of the effusion can be made by the clinical signs, which is not very specific and the cardiac echography. The etiological diagnosis remains difficult because it requires the elimination of the other causes of pericarditis. Their treatment consists in evacuating the pericardial effusion. The evolution thereafter is simple. We report four cases of patients with pericardial effusion late after a thoracic injury. Imaging the blood test, the examination of the pericardial fluid and the anatomopathological examination of the pericardium, eliminates the other etiologies.

Cardiac tamponade: an educational review

Cardiac tamponade is a pericardial syndrome characterised by an impairment of the diastolic filling of the ventricles causing reduction of cardiac output, usually producing signs and symptoms of cardiac arrest, if untreated. The main causes of cardiac tamponade include percutaneous cardiac interventions, malignacies, infectious/inflammatory causes, mechanical complications of myocardial infarction and aortic dissection. The diagnosis of cardiac tamponade is a clinical diagnosis based on a suggestive history and clinical presentation with worsening dyspnoea, distended jugular veins, muffled heart sounds and pulsus paradoxus, and should be confirmed by echocardiography. Cardiac tamponade is a life-threatening syndrome that requires urgent treatment by pericardiocentesis. Pericardiocentesis is an interventional technique to drain pericardial fluid by a percutaneous route. The standard technique for pericardiocentesis is guided by echocardiography or fluoroscopy under local anaesthesia. Pericardiocentesis should be performed by experienced operators and carries a variable risk of complications, mainly cardiac chamber puncture, arrhythmias (ventricular arrhythmias suggest puncture of the ventricle), coronary artery puncture or haemothorax, pneumothorax, pneumopericardium and hepatic injury. The prognosis of cardiac tamponade is essentially related to aetiology. Cardiac tamponade in patients with cancer and metastatic involvement of the pericardium has a bad short-term prognosis because it is a sign of advanced cancer, on the contrary, patients with cardiac tamponade and a final diagnosis of idiopathic pericarditis generally have a good long-term prognosis.

High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update)

Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.

Back to Basics: Key Physical Examinations and Theories in Patients with Heart Failure

Heart failure (HF) is a leading cause of hospitalization. Suitable pharmacologic management is critical. Distinct physical findings such as congestion and peripheral hypoperfusion need to be considered in selecting pharmacologic therapy. By applying the pretest probability and likelihood ratios of unique physical findings of HF to a Markov model, a definite posttest probability can be obtained. This article focuses on the findings of S3, jugular venous pressure, proportional pulse pressure, bendopnea, trepopnea, and various heart murmurs. Incorporating statistical precision in physical assessments, diagnoses of HF can be further refined, providing a sophisticated approach to evaluate patients hemodynamics status noninvasively.

Life-threatening Development of Cardiac Tamponade in the Span of 24 Hours

Cardiac tamponade is a medical emergency that requires immediate treatment. Caused by the development of fluid in the pericardial space, it can result in a severe decrease in cardiac output. When encountering patients with severe hypotension and tachycardia, emergency physicians must always consider the diagnosis of tamponade to facilitate prompt and effective treatment and stabilization. We report our experience with a patient who developed life-threatening cardiac tamponade within a span of less than 24 hours.

Usefulness of Oximetry Paradoxus to Diagnose Cardiac Tamponade

Although echocardiography is usually diagnostic of cardiac tamponade, it may not be readily available at the point-of-care. We sought to develop and validate a measurement of respirophasic variation in the amplitude of pulse oximetry plethysmographic waveforms as a diagnostic tool for cardiac tamponade. Pulse oximetry plethysmographic waveforms were recorded, and the ratio of maximum-to-minimum measured amplitude of these waveforms from one respiratory cycle was calculated by blinded observers. Ratios from 3 consecutive respiratory cycles were then averaged to derive an "oximetry paradoxus" ratio. Cardiac tamponade was independently confirmed or excluded according to a "blinded" objective interpretation of echocardiography or right heart catheterization. Seventy four subjects were enrolled (51% men; mean age 54 ± 15 years); 19 of whom had cardiac tamponade. Oximetry paradoxus area under the curve for diagnosis of cardiac tamponade was 0.90 (95% confidence interval, 0.84 to 0.97); its diagnostic performance was superior to sphygmomanometer-measured pulsus paradoxus (area under the curve difference = 0.16, p = 0.022). In a derivation cohort (n = 37; tamponade, 9 cases), 3 diagnostic oximetry paradoxus thresholds were identified and validated in an independent validation cohort (n = 37; tamponade, 10 cases): 1.2 (100% sensitivity, 44% specificity), 1.5 (80% sensitivity, 81% specificity), and 1.7 (80% sensitivity, 89% specificity). Furthermore, oximetry paradoxus was significantly reduced after draining pericardial fluid. In conclusion, we defined and validated oximetry paradoxus as a simple and ubiquitous point-of-care test to diagnose cardiac tamponade using respirophasic changes in pulse plethysmography waveforms. This test can aid in identifying patients with cardiac tamponade, thus expediting confirmatory testing and life-saving treatment.

Pulsus paradoxus

OBJECTIVES

Reviewed the etiologies, pathophysiologic mechanisms, detection and clinical significance of pulsus paradoxus in various conditions.

DATA SOURCE

We searched PubMed, EMBASE, and the CINAHL from inception to June 2017. We used the following search terms: Pulsus paradoxus, pericardial effusion, acute asthma, ventricular interdependence and so forth. All types of study were chosen.

RESULTS AND CONCLUSION

Legendary physician Sir William Osler truly said that "Medicine is learned by the bedside and not in the classroom." Bedside history taking and physical examination should be an integral component of clinical teaching curriculum imparted to medical students. Pulsus paradoxus is a valuable physical sign seen in many clinical conditions. Pulsus paradoxus is defined by an inspiratory fall in systolic blood pressure of greater than 10 mm Hg. Two prototype examples of pulsus paradoxus are cardiac tamponade and acute asthma. Exaggerated swings of intrapleural pressure, bi-ventricular interactions and increase afterload of the left ventricle are few of the pathophysiological mechanisms involved in the causation of pulsus paradoxus. The sensitivity of pulsus paradoxus in the diagnosis of cardiac tamponade is very high. In acute asthma, it also correlates with the severity of airflow obstruction.

Outcomes of idiopathic chronic large pericardial effusion

Objective

Aim of this paper is to evaluate the outcomes of ‘idiopathic’ chronic large pericardial effusions without initial evidence of pericarditis.

Methods

All consecutive cases of idiopathic chronic large pericardial effusions evaluated from 2000 to 2015 in three Italian tertiary referral centres for pericardial diseases were enrolled in a prospective cohort study. The term ‘idiopathic’ was applied to cases that performed a complete diagnostic evaluation to exclude a specific aetiology. A clinical and echocardiographic follow-up was performed every 3–6 months.

Results

100 patients were included (mean age 61.3±14.6 years, 54 females, 44 patients were asymptomatic according to clinical evaluation) with a mean follow-up of 50 months. The baseline median size of the effusion (evaluated as the largest end-diastolic echo-free space) was 25 mm (IQR 8) and decreased to a mean value of 7 mm (IQR 19; p<0.0001) with complete regression in 39 patients at the end of follow-up. There were no new aetiological diagnoses. Adverse events were respectively: cardiac tamponade in 8 patients (8.0%), pericardiocentesis in 30 patients (30.0%), pericardial window in 12 cases (12.0%) and pericardiectomy in 3 patients (3.0%). Recurrence-free survival and complications-free survival was better in patients treated without interventions (log rank p=0.0038).

Conclusions

The evolution of ‘idiopathic’ chronic large pericardial effusions is usually benign with reduction of the size of the effusion in the majority of cases, and regression in about 40% of cases. The risk of cardiac tamponade is 2.2%/year and recurrence/complications survival was better in patients treated conservatively without interventions.

Fatal Myopericarditis Following an Influenza A (H3N2) Infection

Patient: Female, 14

Final Diagnosis: Myopericarditis

Symptoms: Cardiac tamponade • dyspnea • pericardial effusion • tachycardia

Medication: —

Clinical Procedure: Cardiopulmonary resuscitation

Specialty: Infectious Diseases

The Role of Technology in the Bedside Encounter

Technology has the potential to both distract and reconnect providers with their patients. The widespread adoption of electronic medical records in recent years pulls physicians away from time at the bedside. However, when used in conjunction with patients, technology has the potential to bring patients and physicians together. The increasing use of point-of-care ultrasound by physicians is changing the bedside encounter by allowing for real-time diagnosis with the treating physician. It is a powerful example of the way technology can be a force for refocusing on the bedside encounter.

Point-of-Care Diagnosis of Cardiac Tamponade Identified by the Flow Velocity Paradoxus

The presentation of cardiac tamponade is a spectrum from occult to extreme. The clinical history, physical exam, electrocardiogram, and radiographic findings of tamponade have poor sensitivities and even worse specificities. We use a clinical scenario to demonstrate how point-of-care cardiac ultrasound can diagnose impending cardiac tamponade in a clinically stable patient. The ultrasound finding we recommend is the flow velocity paradoxus, in which respiratory variation causes significant changes in transvalvular inflow velocities, which are exaggerated when tamponade is present. The management of a pericardial effusion depends on its physiologic effect, and point-of-care ultrasound directly measures that effect and expedites patient care.

Team-based approach to identify cardiac toxicity in critically ill hematopoietic stem cell transplant recipients

INTRODUCTION

We observed pulmonary hypertension (PH), pericardial effusions, and left ventricular systolic dysfunction (LVSD) in multiple critically ill hematopoietic stem cell transplant (HSCT) recipients. We implemented routine structured echocardiography screening for HSCT recipients admitted to the pediatric intensive care unit (PICU) using a standardized multidisciplinary process.

METHODS

HSCT recipients admitted to the PICU with respiratory distress, hypoxia, shock, and complications related to transplant-associated thrombotic microangiopathy were screened on admission and every 1-2 weeks thereafter. Echocardiography findings requiring intervention and/or further screening included elevated right ventricular pressure, LVSD, and moderate to large pericardial effusions. All echocardiograms were compared to the patient's routine pretransplant echocardiogram.

RESULTS

Seventy HSCT recipients required echocardiography screening over a 3-year period. Echo abnormalities requiring intervention and/or further screening were found in 35 (50%) patients. Twenty-four (34%) patients were noted to have elevated right ventricular pressure; 14 (20%) were at risk for PH, while 10 (14%) had PH. All patients with PH were treated with pulmonary vasodilators. LVSD was noted in 22 (31%) patients; 15/22 (68%) received inotropic support. Moderate to large pericardial effusions were present in nine (13%) patients, with six needing pericardial drain placement.

DISCUSSION

Echocardiographic abnormalities are common in critically ill HSCT recipients. Utilization of echocardiogram screening may allow for early detection and timely intervention for cardiac complications in this high-risk cohort.

Emergency department point-of-care ultrasonography improves time to pericardiocentesis for clinically significant effusions

Objective

Our objective was to determine the utility of point-of-care ultrasound (POCUS) to identify and guide treatment of tamponade or clinically significant pericardial effusions in the emergency department (ED).

Methods

This was a retrospective cohort study of non-trauma patients who were diagnosed with large pericardial effusions or tamponade by the ED physician using POCUS. The control group was composed of those patients later diagnosed on the medical wards or incidentally in the ED by other means such as a computed tomography. The following data were abstracted from the patient’s file: demographics, medical background, electrocardiogram results, chest radiograph readings, echocardiogram results, and patient outcomes.

Results

There were 18 patients in the POCUS arm and 55 in the control group. The POCUS arm had a decreased time to pericardiocentesis (11.3 vs. 70.2 hours, P=0.055) as well as a shorter length of stay (5.1 vs. 7.0 days, P=0.222). A decreased volume of pericardial fluid was drained (661 vs. 826 mL, P=0.139) in the group diagnosed by POCUS.

Conclusion

This study suggests that POCUS may effectively identify pericardial effusions and guide appropriate treatment, leading to a decreased time to pericardiocentesis and decreased length of hospital stay. Pericardial tamponade or a large pericardial effusion should be considered in all patients presenting to the ED with clinical, radiographic, or electrocardiographic signs of cardiovascular compromise.

Right Ventricular Perforation and Subsequent Cardiac Tamponade Caused by IVC Filter Strut Fracture Migration

Cardiac tamponade, if not recognized and treated immediately, is a life threatening condition with various etiologies. Most common causes of cardiac tamponade encountered in emergency rooms are due to trauma, post myocardial infarction wall rupture, cancer and all other causes of pericardial effusion. Iatrogenic causes of cardiac tamponade include anticoagulation and procedures related. Currently there is a general comfort level amongst physicians that inferior vena cava (IVC) filters are not associated with significant complications. However, one of the feared life-threatening immediate complications of IVC filter placement is complete migration of the filter to the heart, with possible risk for cardiac arrhythmia, cardiac tamponade, and death. IVC filter strut fracture and migration to the heart and pulmonary arteries is another possible cause of cardiac tamponade and needs to be added to the differential diagnosis in the setting of tamponade signs and symptoms in a patient with history of IVC filter placement. We present a case of IVC filter strut fracture and migration to the right ventricle with penetration of the free wall causing cardiac tamponade with subsequent successful percutaneous retrieval. We hope to raise awareness through this case of the rare but potentially fatal complications of IVC filter placement and to advise regarding the judicious use of IVC filters.

Cough induced syncope: A hint to cardiac tamponade diagnosis

We report a case of a 75-year-old male with history of lung adenocarcinoma who presented with shortness of breath and frequent episodes of cough-induced syncope. A large pericardial effusion was found on echocardiogram suggestive of cardiac tamponade. Pericardiocentesis was done which improved the dyspnea and eventually resolved the syncope. There are only two other cases reported in the literature with cough-induced syncope in the setting of pericardial effusion or cardiac tamponade. Our clinical vignette also highlights the importance of pulsus paradoxus identification in patients with cough induced syncope to rule out cardiac tamponade since this is the most sensitive physical finding for its diagnosis.

Emergencies in Hematology and Oncology

The development of medical emergencies related to the underlying disease or as a result of complications of therapy are common in patients with hematologic or solid tumors. These oncological emergencies can occur as an initial presentation or in a patient with an established diagnosis and are encountered in all medical care settings, ranging from primary care to the emergency department and various subspecialty environments. Therefore, it is critically important that all physicians have a working knowledge of the potential oncological emergencies that may present in their practice and how to provide the most effective care without delay. This article reviews the most common oncological emergencies and provides practical guidance for initial management of these patients.