What echocardiographic findings suggest a pericardial effusion is causing tamponade?

Cardiac Point-Of-Care Ultrasound: An Emergency Medicine Review

Cardiac point-of-care ultrasound (POCUS) can make critical diagnoses and monitor the response to interventions. In contrast with consultative echocardiography, cardiac POCUS serves to answer a specific clinical question. This imaging modality can be used to evaluate for left ventricular systolic and diastolic dysfunction, pericardial effusion and tamponade, acute and chronic right ventricular dysfunction, valvular dysfunction, and cardiac activity in cardiac arrest.

Is pulmonary hypertension protective against cardiac tamponade? A systematic review

The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.

Critical Care Ultrasound in Shock: A Comprehensive Review of Ultrasound Protocol for Hemodynamic Assessment in the Intensive Care Unit

Shock is a life-threatening condition that requires prompt recognition and treatment to prevent organ failure. In the intensive care unit, shock is a common presentation, and its management is challenging. Critical care ultrasound has emerged as a reliable and reproducible tool in diagnosing and classifying shock. This comprehensive review proposes an ultrasound-based protocol for the hemodynamic assessment of shock to guide its management in the ICU. The protocol classifies shock as either low or high cardiac index and differentiates obstructive, hypovolemic, cardiogenic, and distributive etiologies. In distributive shock, the protocol proposes a hemodynamic-based approach that considers the presence of dynamic obstruction, fluid responsiveness, fluid tolerance, and ventriculo-arterial coupling. The protocol gives value to quantitative measures based on critical care ultrasound to guide hemodynamic management. Using critical care ultrasound for a comprehensive hemodynamic assessment can help clinicians diagnose the etiology of shock and define the appropriate treatment while monitoring the response. The protocol's use in the ICU can facilitate prompt recognition, diagnosis, and management of shock, ultimately improving patient outcomes.

The Role of POCUS and Monitoring Systems during Emergency Pericardial Effusion in the NICU

Central venous catheterization is, now, one of the most routinely used procedures in the NICUs, helping during the care of very sick infants. Pericardial effusion is a very rare but severe complication, with a high mortality. The cases described are part of an ongoing retrospective study where the use of central catheters inserted in our surgical NICU, and its complications is being analyzed. 16 cases over 13 years are presented in this article, varying in severity from mild, self-resolving cases that were discovered during routine cardiac POCUS to cases with important hemodynamic impact associated with cardiac tamponade and cardiac arrest. Due to immediate intervention, only one of the cases led to catheter-related mortality and that was under particular conditions. Our aim is to highlight the severity of this complication, the importance of early intervention, and the impact of a highly technologized unit and widely available cardiac POCUS.

Pericardial tamponade: a new perspective on echocardiographic features and application of a prediction score

Few clinical decision rules have been used to guide clinical management and predict outcomes in patients with pericardial tamponade. The objectives of this study are to identify the echocardiographic features associated with adverse outcomes in patients with pericardial effusions requiring pericardiocentesis and to apply a previously described four-point clinical and echocardiographic score to predict clinical outcomes over 24-hr, 30-day, and 1-year intervals. We performed a retrospective cohort review of patients who had transthoracic echocardiogram (TTE) performed and underwent pericardiocentesis within 48 h of emergency department presentation at two large tertiary care institutions. We constructed different stepwise logistic regression models and examined the associations of TTE characteristics and clinical features with ICU admission, hospital length of stay (h-LOS), and survival. The data set was then employed against a previously proposed scoring system to predict factors associated with clinical outcomes over 24 hr, 30 days, and 1 year. Two hundred thirty-nine patients were included in the final analysis. Echocardiographic characteristics of patients with pericardial tamponade who underwent pericardiocentesis are as follows: 69.1% right ventricular (RV) diastolic collapse, 62.3% exaggerated mitral valve (MV) inflow velocities, 56.4% inferior vena cava (IVC) plethora, and 53.4% right atrial (RA) systolic collapse. Increase in systolic blood pressure and increased variation in MV inflow velocity were associated with reduced ICU admission [OR: 0.94 (CI 0.90, 0.99), 0.28 (CI 0.09, 0.89), respectively]. In addition, a history of malignancy increased the length of hospital stay by about 3.89 days (CI 1.43-6.35, p < 0.01) and prior pericardiocentesis history was associated with 4.82-day increase in hospital stay (CI 1.19-8.45, p = 0.01). In utilizing the previously published prediction score, we found no statistically significant correlation in predicting survival. RV diastolic collapse and exaggerated MV inflow velocity were the most common echocardiographic findings in patients requiring pericardiocentesis. Contrary to prior studies, exaggerated MV inflow velocity was associated with reduced ICU admission. In addition, a previously described prediction score did not correlate with decreased survival in this cohort.

Cardiac Tamponade and Pericardiocentesis: Recognition, Standard Techniques, and Modern Advancements

Pericardiocentesis is an important diagnostic and therapeutic procedure. In the setting of cardiac tamponade, pericardiocentesis can rapidly improve hemodynamics, and in cases of diagnostic uncertainty, pericardiocentesis allows for fluid analysis to aid in diagnosis. In contemporary practice, the widespread availability of ultrasonography has made echocardiographic guidance the standard of care. Additional tools such as micropuncture technique, live ultrasonographic guidance, and adjunctive tools including fluoroscopy continue to advance and enhance procedural efficiency and safety. When performed by experienced operators, pericardiocentesis is a safe, effective, and potentially life-saving procedure.

Thrombotic Microangiopathy After Hematopoietic Stem Cell and Solid Organ Transplantation: A Review for Intensive Care Physicians

Intensive care physicians may assume the primary care of patients with transplant-associated thrombotic microangiopathy (TA-TMA), an uncommon but potentially critical complication of hematopoietic stem cell transplants (HSCTs) and solid organ transplants. TA-TMA can have a dramatic presentation with multiple organ dysfunction syndrome (MODS) associated with high morbidity and mortality. The typical presenting clinical features are hemolytic anemia, thrombocytopenia, refractory hypertension, proteinuria and worsening renal failure. Intestinal involvement, with abdominal pain, nausea and vomiting, gastrointestinal bleeding, and ascites are also common. Cardiopulmonary involvement may develop from various causes including pulmonary arteriolar hypertension, pleural and pericardial effusions, and diffuse alveolar hemorrhage. Due to other often concurrent complications after HSCT, early diagnosis and effective management of TA-TMA may be challenging. Close collaboration between ICU and transplant physicians, along with other relevant specialists, is needed to best manage these patients. There are currently no approved therapies for the treatment of TA-TMA. Plasma exchange and rituximab are not recommended unless circulating factor H (CFH) antibodies or thrombotic thrombocytopenic purpura (TTP; ADAMTS activity < 10%) are diagnosed or highly suspected. The role of the complement pathway activation in the pathophysiology of TA-TMA has led to the successful use of targeted complement inhibitors, such as eculizumab. However, the relatively larger studies using eculizumab have been mostly conducted in the pediatric population with limited data on the adult population. This review is focused on the role of intensive care physicians to emphasize the clinical approach to patients with suspected TA-TMA and to discuss diagnosis and treatment strategies.

Re-enforcing High-Risk Acute Pericarditis Requiring Hospital Admission: An Unusual Case of Critical Idiopathic Acute Pericarditis Presenting As Tamponade and Pleuro-Pericardial Complications in a Patient Presenting With Flu-Like Symptoms

Pericarditis is an inflammatory process that affects the pericardium, the fibrous sac surrounding the heart. Acute pericarditis accounts for approximately 0.1% of inpatient admissions and 5% of non-ischemic chest pain visits to the emergency departments (EDs). Most patients who present with acute pericarditis have a benign course and good prognosis. However, a rare percent of the patients develop complicated pericarditis. Examples of complications include pericardiac effusion, cardiac tamponade, constrictive pericarditis, effusive and constrictive pericarditis and, even more rarely, large pleural effusion The occurrence of complicated pericarditis can lead to high morbidity and mortality if not urgently managed in most patients. Our case presents a 60-year-old male that presented to the emergency room with flu-like symptoms. However, the viral panel test was negative. He initially got discharged with supportive care but was brought back to the ED by his wife in a critical, life-threatening state due to pericarditis symptoms complicated by tamponade and shock. His condition required urgent intervention and critical level of care. The patient's course was also complicated by myopericarditis and recurrent bilateral pleural effusions, which required therapeutic interventions. This unique case presents the patient group that develop multiple life-threatening complications of acute pericarditis, including cardiac tamponade and shock, affecting several end organs. This case also highlights clues to the predisposing factors to complications of acute pericarditis. Patients who present with high-risk signs and symptoms indicating poorer prognosis warrant further observation and admission. This will also add to the literature reviews regarding the risk factors associated with development of complicated acute pericarditis. This will also serve as a review of pathophysiology, etiology, current diagnosis and available novel treatment for such patients.

Spontaneous Hemorrhagic Pericardial Effusion as a Consequence of Apixaban Utilization for New-Onset Atrial Fibrillation

Although anticoagulation stands as a standardized therapeutic approach for mitigating thrombotic risks in atrial fibrillation, the potential for bleeding associated with direct oral anticoagulants (DOACs) is consistently weighed in the risk/benefit analysis prior to initiating therapy for non-valvular atrial fibrillation. While the typical bleeding risks from DOACs predominantly affect the gastrointestinal system, occurrences of spontaneous hemorrhagic pericardial effusions are rare. This case presentation illustrates a patient developing spontaneous hemorrhagic pericardial effusion four days after commencing apixaban therapy and subsequent management.

Point-of-Care Echocardiographic Evaluation of the Pericardium

Acute pericardial conditions, such as tamponade, are often rapidly progressive and can become life-threatening without timely diagnosis and intervention. In this review, we aim to describe bedside ultrasonographic evaluation of the pericardium and diagnostic criteria for tamponade, identify confounders in the diagnosis of pericardial tamponade, and delineate procedural details of ultrasound-guided pericardiocentesis.

Pericardial effusion in children at tertiary national referral hospital, Addis Ababa, Ethiopia: a 7-year institution based review

BACKGROUND

Pericardial effusion (PE) is a rare yet an important cause of child mortality due to collection of excess fluid in pericardial space. The study aimed to describe the PE profile in the national cardiac referral hospital, Addis Ababa, Ethiopia.

METHODS

The study employed cross-sectional study design for a 7-year review of childhood PE in Tikur Anbessa Specialized Hospital. Descriptive and analytic statistics were applied.

RESULTS

There were 17,386 pediatric emergency/ER admissions during the study period, and PE contributed to 0.47% of ER admissions. From 71 included subjects, 59% (42) were males with mean age of 7.8 ± 3.3 years. Cough or shortness of breath,73.2% (52) and fever or fast breathing, 26.7% (19), were the common presenting symptoms. The median duration of an illness before presentation was 14days (IQR: 8-20). The etiologies for pericardial effusion were infective (culture positive-23.9%, culture negative-43.6%, tuberculous-4.2%), hypothyroidism (4.2%), inflammatory (12.7%), malignancy (7%) or secondary to chronic kidney disease (1. 4%). Staphylococcus aureus was the most common isolated bacteria on blood culture, 12.7% (9) while the rest were pseudomonas, 7% (5) and klebsiella, 4.2% (3). Mild, moderate and severe pericardial effusion was documented in 22.5% (16), 46.5% (33), and 31% (22) of study subjects, respectively. Pericardial tamponade was reported in 50.7% (36) of subjects. Pericardial drainage procedure (pericardiocentesis, window or pericardiotomy) was performed for 52.1% (37) PE cases. The case fatality of PE was 12.7% (9). Pericardial drainage procedure was inversely related to mortality, adjusted odds ratio 0.11(0.01-0.99), p 0.049).

CONCLUSION

PE contributed to 0.47% of ER admissions. The commonest PE presentation was respiratory symptoms of around two weeks duration. Purulent pericarditis of staphylococcal etiology was the commonest cause of PE and the case fatality rate was 12.7%. Pericardial drainage procedures contributed to reduction in mortality. All PE cases should be assessed for pericardial drainage procedure to avoid mortality.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Clinical presentation, echocardiographic findings, treatment strategies, and prognosis of dogs with myxomatous mitral valve disease presented with pericardial effusion due to suspected left atrial tear: a retrospective case-control study

INTRODUCTION/OBJECTIVES

Left atrial tear (LAT) is a life-threatening complication in dogs with myxomatous mitral valve disease (MMVD). The study objective was to describe clinical presentation, echocardiographic findings, treatment strategies, and survival in dogs with LAT compared to a control group of dogs with a similar stage of MMVD but no LAT. ANIMALS AND MATERIALS AND METHODS: two-center retrospective case-controlled study including 15 dogs with and 15 dogs without LAT was conducted. Clinical and echocardiographic data were reviewed, and survival information were collected.

RESULTS

Nine dogs in each group were in stage C of MMVD, while the remaining were in stage B2. No differences between groups were found regarding age, body weight, sex, kidney values, and echocardiography-derived cardiac dimensions. Most reported clinical signs associated with LAT included weakness, respiratory signs, and syncope. Treatment varied and was mainly focused on the management of congestive heart failure. Three dogs with LAT received a pericardiocentesis. All 15 dogs with LAT had died of cardiac causes, 5 dogs during the first 7 days after admission. The median survival time for all 15 dogs with LAT was 52 days compared to 336 days in the control group (P=0.103). When excluding 5 dogs with LAT that died during the first 7 days, the median survival increased to 407 days, not different compared to the control group (P=0.549).

CONCLUSIONS

Dogs with MMVD and LAT have a high short-term mortality; however, when surviving the acute phase, the long-term prognosis may not differ from dogs with a similarly advanced degree of MMVD but without LAT.

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.

Pericardial Windows: The Limited Diagnostic Value of Non-Targeted Pericardial Biopsy

BACKGROUND

Pericardial window, in addition to promoting pericardial drainage, can also provide samples of the pericardium for anatomopathological examination. However, such biopsies' contribution to clarifying the etiology of pericardial effusion has been debated.

OBJECTIVE

To analyze the diagnostic value of non-targeted pericardial biopsy obtained from pericardial window procedures.

METHODS

Data from 80 patients who had undergone parietal pericardial biopsies from 2011 to 2020 were retrospectively reviewed. Statistical significance was considered if p < 0.05.

RESULTS

Fifty patients were male (62.5%,) and 30 were female (37.5%). The median age was 52 years (interquartile range: 29 to 59) and 49 years (interquartile range: 38 to 65), respectively (p = 0.724). The suspected etiology of pericardial effusion was neoplastic in 31.3%, unclear in 25%, tuberculosis in 15%, autoimmune in 12.5%, edemagenic syndrome in 7.5%, and other miscellaneous conditions in 8.8%. The most frequent approach for pericardial drainage and biopsy was subxiphoid (74%), followed by video-assisted thoracoscopy (22%). Overall, in 78.8% of the biopsies, the histopathologic findings were compatible with nonspecific inflammation, and only 13.7% of all biopsies yielded a conclusive histopathological diagnostic. Those suffering from cancer and pericardial effusion had a higher proportion of conclusive histopathologic findings (32% had pericardial neoplastic infiltration). The hospital mortality rate was 27.5%, and 54.5% of the patients who died in the hospital had cancer. No deaths were attributed to cardiac tamponade or the drainage procedure.

CONCLUSION

Our results showed that pericardial window is a safe procedure, but it had little value to clarify the pericardial effusion etiology and no impact on the planned therapy for the primary diagnosis besides the cardiac decompression.

Perioperative Point of Care Ultrasound for Hemodynamic Assessment: A Narrative Review

While transesophageal echocardiography (TEE) has traditionally been used in perioperative care, there is growing evidence supporting point of care ultrasound (POCUS) for the anesthesiologist in guiding patient care. It is a quick way to non-invasively evaluate hemodynamically unstable patients and ascertain their state of shock, determine volume status, and guide resuscitation in cardiac arrest. In addition, through use of POCUS, the anesthesiologist is able to identify signs of chronic heart disease to provide a more tailored and safer approach to perioperative care.

Cardiac POCUS in Pediatric Emergency Medicine: A Narrative Review

PURPOSE OF THIS REVIEW

The cardiac point of care ultrasound (POCUS) is among the most impactful examinations in the evaluation of an ill child. This paper will review the English-language literature on cardiac POCUS in the pediatric emergency department (PED), the adult emergency literature with relevance to pediatric emergency, and other pediatric cardiac studies outside pediatric emergency with relevance to PED detection of potentially emergent pediatric cardiac pathology.

RECENT FINDINGS

Pediatric emergency physicians can reliably detect decreased left-sided systolic function and pericardial effusion using POCUS. Case reports show that pediatric emergency physicians have detected right-sided outflow tract obstruction, aortic root dilatation, and congenital cardiac disease using POCUS. Training for pediatric cardiac POCUS competency is feasible, and cardiac POCUS does not increase the burden on cardiology resources to the PED.

SUMMARY

While cardiac pathology in children is relatively rare, pediatric cardiac POCUS can incorporate a broad curriculum beyond systolic function and the presence of pericardial fluid. Further research should assess pediatric emergency physician performance in the identification of a broader range of cardiac pathology.

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.

Agreement on Interpretation of Point-of-Care Ultrasonography for Cardiac Tamponade Among Emergency Physicians

STUDY OBJECTIVE

Cardiac tamponade is an impending calamitous disorder that emergency physicians need to consider and diagnose rapidly. A pericardial effusion with right atrial systolic collapse (earliest sign) or right ventricular diastolic collapse (most specific sign) and a plethoric inferior vena cava are indicators of cardiac tamponade physiology and may be identified with point-of-care ultrasonography (POCUS). The goal of this study is to assess the agreement among emergency physicians with varying levels of sonographic training and expertise in interpreting echocardiographic signs of cardiac tamponade in adult patients.  Methods: Emergency physicians at different levels of training as sonographers were surveyed at didactic conferences at three major academic medical centers in northern New Jersey. Two cardiologists were also included in the study for comparison. Survey respondents were shown 15, 20-second video clips of patients who had presented to the emergency department (ED) with or without significant pericardial effusions and were asked to rate whether tamponade physiology was present or not. Data were collected anonymously on Google Forms (Google LLC, Mountain View, CA) and included self-reported levels of POCUS expertise and level of training. Data were analyzed using Fleiss' kappa (k). All patients had an echocardiogram performed by the department of cardiology within 24 hours of the POCUS, and the results are presented in the paper.  Results: There were 97 participant raters, including attendings, fellows, and resident physicians specializing in adult emergency medicine and two cardiologists. There was a fair degree of inter-rater agreement among all participants in interpreting whether tamponade physiology was present or not. This low level of agreement persisted across self-reported training levels and self-reported POCUS expertise, even at the expert level in both emergency medicine and cardiology specialties.

CONCLUSION

According to the results of our study, there appears to be a low level of agreement in the interpretation of cardiac tamponade in adult patients. The lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise. This low level of agreement seen among both specialists indicates that emergency physicians are not limited in their ability to determine cardiac tamponade on POCUS. This highlights the technical nature of POCUS clips and strengthens the importance of physical exam findings when diagnosing cardiac tamponade in emergency department patients. Further research utilizing POCUS for the diagnosis of tamponade is warranted.

Not all Shock States Are Created Equal: A Review of the Diagnosis and Management of Septic, Hypovolemic, Cardiogenic, Obstructive, and Distributive Shock

Shock in the critically ill patient is common and associated with poor outcomes. Categories include distributive, hypovolemic, obstructive, and cardiogenic, of which distributive (and usually septic distributive) shock is by far the most common. Clinical history, physical examination, and hemodynamic assessments & monitoring help differentiate these states. Specific management necessitates interventions to correct the triggering etiology as well as ongoing resuscitation to maintain physiologic milieu. One shock state may convert to another and may have an undifferentiated presentation; therefore, continual re-assessment is essential. This review provides guidance for intensivists for management of all shock states based on available scientific evidence.

Pericardial tamponade, a diagnostic chameleon: from the historical perspectives to contemporary management

BACKGROUND

Pericardial tamponade (PT) early after cardiac surgery is a challenging clinical entity, not infrequently misrecognized and often only detected late in its course. Because the clinical signs of pericardial tamponade can be very unspecific, a high degree of initial suspicion is required to establish the diagnosis. In addition to clinical examination the deployment of imaging techniques is almost always mandatory in order to avoid delays in diagnosis and to initiate any necessary interventions, such as pericardiocentesis or direct cardiac surgical interventions. After a brief overview of how knowledge of PT has developed throughout history, we report on an atypical life-threatening cardiac tamponade after cardiac surgery. A 74-year-old woman was admitted for elective biological aortic valve replacement and aorto-coronary-bypass grafting (left internal mammary artery to left anterior descending artery, single vein graft to right coronary artery). On the 10th postoperative day, the patient unexpectedly deteriorated. She rapidly developed epigastric pain radiating to the left upper abdomen, and features of low peripheral perfusion and shock. There were no clear signs of pericardial tamponade either clinically or echocardiographically. Therefore, for further differential diagnosis, a contrast-enhanced computed tomography scan was performed under clinical suspicion of acute abdomen. Unexpectedly, active bleeding distally from the right coronary anastomosis was revealed. While the patient was prepared for operative revision, she needed cardiopulmonary resuscitation, which was successful. Intraoperatively, the source of bleeding was located and surgically relieved. The subsequent postoperative course was uneventful.

CONCLUSIONS

In the first days after cardiac surgery, the occurrence of life-threatening situations, such as cardiac tamponade, must be expected. Especially if the symptoms are atypical, the entire diagnostic armamentarium must be applied to identify the origin of the complaints, which may be cardiac, but also non-cardiac.

CENTRAL MESSAGE

A high level of suspicion, immediate diagnostic confirmation, and rapid treatment are required to recognize and successfully treat such an emergency (Fig. 5).

PERSPECTIVE

Pericardial tamponade should always be considered as a complication of cardiac surgery, even when symptoms are atypical. The full range of diagnostic tools must be used to identify the origin of the complaints, which may be cardiac, but also non-cardiac (Fig. 5).

Point-of-care ultrasound use in emergencies: what every anaesthetist should know

Point-of-care ultrasound has been embraced by anaesthetists as an invaluable tool for rapid diagnosis of haemodynamic instability, to ensure procedural safety and monitor response to treatments. Increasingly available, affordable and portable, with emerging evidence of improved patient outcomes, point-of-care ultrasound has become a valuable tool in the emergency setting. This state-of-the-art review describes the feasibility of point-of-care ultrasound practice, training and maintenance of competence. It also describes the many uses of point-of-care ultrasound for the anaesthetist and describes the most salient point-of-care ultrasound views for anaesthetic emergencies including: undifferentiated shock; hypoxemia; and trauma. Procedural safety is also discussed in addition to relevant important governance aspects. Cardiac function should be assessed using the parasternal long axis, parasternal short basal/mid-papillary/apical, apical four chamber and subcostal four chamber views, and should include a visual estimation of global left ventricular ejection fraction. Other cardiovascular conditions that can be identified using point-of-care ultrasound include: pericardial effusion; cardiac tamponade; and pulmonary embolism. Pulmonary emergency conditions that can be diagnosed using point-of-care ultrasound include pneumothorax; pleural effusion; and interstitial syndrome. The extended focused assessment with sonography for trauma examination may of value in patients who are hypotensive in order to identify intra-abdominal haemorrhage, pneumothoraces and haemothoraces.

Cardiac tamponade and septic pericarditis caused by biliary stent migration

In patients with biliary or pancreatic disease, endoscopic retrograde cholangiopancreatography (ERCP) is a common and important therapeutic and diagnostic procedure. Stent migration is a possible complication occurring in approximately 5-10% of cases. This case presents a 47-year-old male with chest pain and found to have biliary stent migration to the pericardial sac causing septic pericarditis and cardiac tamponade. Highlighting this devastating complication, this case demonstrates an opportunity for emergency physicians (EP) to diagnose and monitor patients for post-operative and post-procedural complications. In the emergency department, EPs are well positioned to use ultrasound as a diagnostic and monitoring tool for cardiac tamponade.

Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review

Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.

Advanced and Invasive Cardiopulmonary Resuscitation (CPR) Techniques as an Adjunct to Advanced Cardiac Life Support

BACKGROUND

Despite numerous promising innovations, the chance of survival from sudden cardiac arrest has remained virtually unchanged for decades. Recently, technological advances have been made, user-friendly portable devices have been developed, and advanced invasive procedures have been described that could improve this unsatisfactory situation.

METHODS

A selective literature search in the core databases with a focus on randomized controlled trials and guidelines.

RESULTS

Technical aids, such as feedback systems or automated mechanical cardiopulmonary resuscitation (CPR) devices, can improve chest compression quality. The latter, as well as extracorporeal CPR, might serve as a bridge to treatment (with extracorporeal CPR even as a bridge to recovery). Sonography may be used to improve thoracic compressions on the one hand and to rule out potentially reversible causes of cardiac arrest on the other. Resuscitative endovascular balloon occlusion of the aorta might enhance myocardial and cerebral perfusion. Minithoracostomy, pericardiocentesis, or clamshell thoracotomy might resolve reversible causes of cardiac arrest.

CONCLUSIONS

It is crucial to identify those patients who may benefit from an advanced or invasive procedure and make the decision to implement the intervention in a timely manner. As with all infrequently performed procedures, sound education and regular training are paramount.

Helicopter Emergency Medical Services Ultrasound Use in the Diagnosis of Pericardial Effusion Due to Aortic Dissection

Ultrasound has historically been limited to in-hospital use for the diagnosis and management of various conditions. However, with the advent of smaller and more portable devices, this technology can be used outside the hospital. This report describes a patient with chest pain and hypotension for whom a point-of-care cardiac ultrasound (POCUS) was performed to diagnose cardiac tamponade during critical care transport. She was subsequently found to have an acute type A aortic dissection, and her care was expedited to the operating room. Cardiac tamponade in the setting of acute type A aortic dissection requires urgent surgical repair; therefore, early diagnosis is crucial to survival. In this case, prehospital ultrasound facilitated rapid care for the patient. Further study is needed to define its role in the prehospital setting.

Multimodality Imaging of Sudden Cardiac Death and Acute Complications in Acute Coronary Syndrome

Sudden cardiac death (SCD) is a potentially fatal event usually caused by a cardiac arrhythmia, which is often the result of coronary artery disease (CAD). Up to 80% of patients suffering from SCD have concomitant CAD. Arrhythmic complications may occur in patients with acute coronary syndrome (ACS) before admission, during revascularization procedures, and in hospital intensive care monitoring. In addition, about 20% of patients who survive cardiac arrest develop a transmural myocardial infarction (MI). Prevention of ACS can be evaluated in selected patients using cardiac computed tomography angiography (CCTA), while diagnosis can be depicted using electrocardiography (ECG), and complications can be evaluated with cardiac magnetic resonance (CMR) and echocardiography. CCTA can evaluate plaque, burden of disease, stenosis, and adverse plaque characteristics, in patients with chest pain. ECG and echocardiography are the first-line tests for ACS and are affordable and useful for diagnosis. CMR can evaluate function and the presence of complications after ACS, such as development of ventricular thrombus and presence of myocardial tissue characterization abnormalities that can be the substrate of ventricular arrhythmias.

Cardiac Tamponade, an Unusual First Presentation of Systemic Lupus Erythematosus: A Case Report in a Rural Tertiary Hospital

Systemic lupus erythematosus (SLE) is a condition that manifests in a variety of ways. Although pericarditis and pericardial effusion are frequent cardiac manifestations of SLE, cardiac tamponade is rarely reported, especially as the initial manifestation of the disease. We describe a 38-year-old Nigerian lady who presented with three months of progressive dyspnea. She had intermittent fever, tachycardia, tachypnea, hypotension, jugular vein distension, and muffled heart sounds. Echocardiography confirmed cardiac tamponade. The ANA, anti-dsDNA, and anti-Sm antibodies were positive. She had a high ESR and low levels of blood complements. The diagnosis of SLE was established based on the 2019 EULAR/ACR classification criteria. She was treated with intravenous methylprednisolone, oral prednisolone, and hydroxychloroquine after undergoing an emergency echo-guided pericardiocentesis. She responded well to treatment, and she is currently being followed up on an outpatient basis. Clinicians should consider SLE as a differential when evaluating patients with pericardial effusion, as an accurate and timely diagnosis could be lifesaving.

Streptococcus anginosus purulent pericarditis with cardiac tamponade presenting as a complication of postobstructive pneumonia

A man in his 60s with stage 3 squamous cell carcinoma of the left lung status postchemotherapy and radiation therapy presented with mixed septic and obstructive shock with multiorgan dysfunction. Initial electrocardiogram showed sinus tachycardia and diffuse concaved ST elevation. Transthoracic echocardiogram revealed pericardial effusion with tamponade physiology. CT thorax was notable for dense left lung consolidation with pleural effusion. Emergent pericardiocentesis and percutaneous balloon pericardiotomy were performed which successfully drained 500 mL of purulent pericardial fluid. A left chest tube was placed and revealed a large volume of empyema. Both pericardial and pleural fluid cultures yielded similar strains of Streptococcus anginosus The patient was initially treated with empiric broad-spectrum intravenous antibiotics which were eventually de-escalated to intravenous ceftriaxone based on microbiology culture and sensitivity. Unfortunately, the patient developed pulseless electrical activity arrest on day 10 of intensive care unit stay and expired despite cardiopulmonary resuscitation.

Cardiac Tamponade Caused by Gastrointestinal Obstruction—A Rare Complication in Esophagectomy Patients

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Postoperative anatomical changes can cause unique disease presentations.

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Tamponade physiology can occur secondary to GI obstruction in esophagectomy patients.

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Point-of-care ultrasound imaging leads to expedited diagnosis and disposition.

Handheld ultrasound is an adjunct to the physical examination in the diagnosis of cardiopulmonary disease

Handheld 2D ultrasound devices (HUDs) have become available as an adjunct to physical examinations, visualizing the heart and lungs in real time and facilitating prompt patient diagnosis and treatment of cardiopulmonar.y disorders. These devices provide simple and rapid bedside alternatives to repetitive chest x-rays, standard ultrasound examinations and thoracic CT scans. Two currently available HUDs are described. This paper discusses the use of HUDs in the diagnosis of patients with pericardial effusion and tamponade, ventricular dilation, aortic and mitral regurgitation, cardiogenic pulmonary edema, viral and bacterial pneumonia, pleural effusion and pneumothorax. The use of a HUD by physicians increases clinical diagnostic accuracy, adds quantitative information about cardiopulmonary disease severity and guides the use of medications and interventions.

The Parasternal Long Axis View in Isolation: Is it Good Enough?

BACKGROUND

Focused cardiac ultrasound (FOCUS) is a vital tool to evaluate patients at the bedside, but its use can be limited by patient habitus, sonographer skill, and time to perform the examination.

OBJECTIVE

Our primary goal was to determine the diagnostic accuracy of the parasternal long axis (PSLA) view in isolation for identifying pericardial effusion, left ventricular (LV) dysfunction, and right ventricular (RV) dilatation compared with a four-view FOCUS examination.

METHODS

This was a retrospective study looking at FOCUS images. Examinations were blinded and randomized for review by point-of-care ultrasound faculty. The primary objective was measured by comparing ultrasound findings on PSLA view in isolation with findings on a full four-view FOCUS examination, which served as the criterion standard. Sensitivity and specificity were calculated.

RESULTS

Of 100 FOCUS examinations; 36% were normal, 16% had a pericardial effusion, 41% had an LV ejection fraction < 50%, and 7% had RV dilatation. Sensitivity and specificity for identifying pericardial effusion, LV dysfunction, and RV dilatation were 81% (confidence interval [CI] 0.54-0.95) and 98% (95% CI 0.91-0.99), 100% (95% CI 0.88-1) and 91% (95% CI 0.80-0.97), and 71% (95% CI 0.30-0.94) and 99% (95% CI 0.93-1), respectively. All moderate to large effusions were identified correctly. Overall, there were only four clinically significant disagreements between PSLA alone and the four-view interpretations.

CONCLUSIONS

In isolation, the PSLA view was highly sensitive and specific for identifying LV ejection fraction and moderate to large pericardial effusions. It was highly specific for identifying RV dilatation, but had only moderate sensitivity.

Clinical Presentation and Management of Methicillin-Resistant Staphylococcus aureus Pericarditis—Systematic Review

In the expanding era of antibiotic resistance, new strains of Staphylococcus aureus have emerged which possess resistance to traditionally used antibiotics (MRSA). Our review aimed to systematically synthesize information on previously described MRSA pericarditis cases. The only criterion for inclusion was the isolation of MRSA from the pericardial space. Our review included 30 adult and 9 pediatric patients (aged: 7 months to 78 years). Comorbid conditions were seen in most adult patients, whereas no comorbidities were noted amongst the pediatric patients. Pericardial effusion was found in 94.9% of cases, with evidence of tamponade in 83.8%. All cases isolated MRSA from pericardial fluid and 25 cases (64.1%) had positive blood cultures for MRSA. Pericardiocentesis and antibiotics were used in all patients. The mortality rate amongst adults was 20.5%, with a mean survival of 21.8 days, and attributed to multi-organ failure associated with septic shock. No mortality was observed in the pediatric population. In adult patients, there was no statistical difference in symptom duration, antibiotic duration, presence of tamponade, age, and sex in relation to survival. Conclusion: MRSA pericarditis often presents with sepsis and is associated with significant mortality. As such, a high clinical suspicion is needed to proceed with proper tests such as echocardiography and pericardiocentesis. In more than one third of the cases, MRSA pericarditis occurs even in the absence of documented bacteremia.

Point-of-care ultrasound for critically-ill patients: A mini-review of key diagnostic features and protocols

Point-of-care ultrasonography (POCUS) for managing critically ill patients is increasingly performed by intensivists or emergency physicians. Results of needs surveys among intensivists reveal emphasis on basic cardiac, lung and abdominal ultrasound, which are the commonest POCUS modalities in the intensive care unit. We therefore aim to describe the key diagnostic features of basic cardiac, lung and abdominal ultrasound as practised by intensivists or emergency physicians in terms of accuracy (sensitivity, specificity), clinical utility and limitations. We also aim to explore POCUS protocols that integrate basic cardiac, lung and abdominal ultrasound, and highlight areas for future research.

Community-associated Methicillin-resistant Staphylococcus aureus pericarditis in an immunocompetent patient

Background

Pericarditis caused by Methicillin-resistant Staphylococcus aureus (MRSA) is a rare infection, often seen in patients with chronic kidney disease, immunosuppression, or previous pericardial disease. The presentation can be dramatic with acute illness leading to septic and/or obstructive shock due to pericardial tamponade. Occasionally disease can have a more protracted, indolent, subacute clinical course.

Case report

We report a case of a 57-year-old male patient with a previous history of smoking and moderate alcohol use who presented with progressive dyspnea and cough. He was found to have a disseminated MRSA infection with pericarditis complicated by pericardial tamponade. Urgent pericardiocentesis yielded 1.1 liters of purulent fluid that grew MRSA. MRSA was also isolated from the blood and pleural fluid. The patient underwent left thoracotomy, decortication, and pericardial window and completed 3 weeks of intravenous vancomycin therapy, concluding in an excellent outcome.

Conclusion

Bacterial pericarditis is an exceptionally rare form of pericarditis which been traditionally associated with chronic medical conditions requiring a prolonged healthcare stay. However, it has lately been observed in healthy individuals with social habits such as smoking and alcohol consumption. Bacterial pericarditis must be recognized in a timely fashion and managed aggressively to prevent a devastating outcome. A multidisciplinary approach is advised, which includes a combination of pericardial drainage and aggressive antibiotic therapy. Such treatment often yields a positive outcome and good long-term prognosis.

Development and evaluation of the focused assessment of sonographic pathologies in the intensive care unit (FASP-ICU) protocol

Background

The use of ultrasonography in the intensive care unit (ICU) is steadily increasing but is usually restricted to examinations of single organs or organ systems. In this study, we combine the ultrasound approaches the most relevant to ICU to design a whole-body ultrasound (WBU) protocol. Recommendations and training schemes for WBU are sparse and lack conclusive evidence. Our aim was therefore to define the range and prevalence of abnormalities detectable by WBU to develop a simple and fast bedside examination protocol, and to evaluate the value of routine surveillance WBU in ICU patients.

Methods

A protocol for focused assessments of sonographic abnormalities of the ocular, vascular, pulmonary, cardiac and abdominal systems was developed to evaluate 99 predefined sonographic entities on the day of admission and on days 3, 6, 10 and 15 of the ICU admission. The study was a clinical prospective single-center trial in 111 consecutive patients admitted to the surgical ICUs of a tertiary university hospital.

Results

A total of 3003 abnormalities demonstrable by sonography were detected in 1275 individual scans of organ systems and 4395 individual single-organ examinations. The rate of previously undetected abnormalities ranged from 6.4 ± 4.2 on the day of admission to 2.9 ± 1.8 on day 15. Based on the sonographic findings, intensive care therapy was altered following 45.1% of examinations. Mean examination time was 18.7 ± 3.2 min, or 1.6 invested minutes per detected abnormality.

Conclusions

Performing the WBU protocol led to therapy changes in 45.1% of the time. Detected sonographic abnormalities showed a high rate of change in the course of the serial assessments, underlining the value of routine ultrasound examinations in the ICU.

Trial registration The study was registered in the German Clinical Trials Register (DRKS, 7 April 2017; retrospectively registered) under the identifier DRKS00010428.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03811-2.

Cardiac Ultrasound for Pediatric Emergencies

Cardiac point-of-care ultrasound (POCUS) provides real-time views of the heart to answer specific questions in a timely manner. This is a valuable tool for managing pediatric patients, from those with congenital heart disease to those who are critically ill. The main echocardiographic findings of pericardial tamponade consist of a pericardial effusion, diastolic right ventricular collapse, systolic right atrial collapse, and a plethoric inferior vena cava with minimal respiratory variation. The main echocardiographic findings of hypertrophic cardiomyopathy consist of increased wall thickness (concentric or eccentric), systolic anterior motion of the anterior mitral leaflet, and a dynamic sub-aortic left ventricular outflow tract obstruction. Additional uses of cardiac POCUS include assessment of dilated cardiomyopathy and the detection of pediatric congenital heart disease, including detection of a patent ductus arteriosus. The use of POCUS in the pediatric population is supported by societal position statements and is expected to develop further with increasingly robust education and training. [Pediatr Ann. 2021;50(10):e424-e431.].