Clinical and historical features of emergency department patients with pericardial effusions

Prehospital Ultrasound Use to Guide Emergent Pericardiocentesis: A Case Report

Point-of-care ultrasound (POCUS) has been shown to be a valuable tool in the management of acutely ill patients in the prehospital setting. POCUS not only has utility from a diagnostic perspective but also has been shown to reduce the rate of complications from otherwise traditionally "blind" procedures, such as pericardiocentesis. This case report highlights the utility of POCUS in the prehospital setting to guide emergent pericardiocentesis to treat cardiac tamponade. The applicability of various approaches to ultrasound-guided pericardiocentesis is also discussed.

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.

54-year-old Woman with Chest Pain

Chest pain is a common presentation to the emergency department (ED) that can be caused by a multitude of etiologies. It can be challenging to differentiate life-threatening conditions from more benign causes. A 54-year-old woman presented to the ED complaining of chest pain with dyspnea in the setting of recent blunt trauma. This case offers a thorough yet practical approach to the diagnostic workup of chest pain with dyspnea in the ED setting. The surprising final diagnosis and case outcome are then revealed.

Apixaban-Induced Spontaneous Hemorrhagic Cardiac Tamponade

Direct oral anticoagulants (DOACs), such as apixaban, are used for the prevention and management of thromboembolic diseases. Here, we present a case of a 72-year-old African American woman who presented to the hospital with shortness of breath and precordial chest pain for three days. The patient was diagnosed with volume overload associated with the progression of chronic kidney disease (CKD) and subsequently admitted to the hospital. Since the patient failed to adequately respond to diuretics, hemodialysis was initiated. During the hospital stay, she developed paroxysmal atrial fibrillation. Along with amiodarone, apixaban was started for primary stroke prophylaxis. Within 72 hours, the patient developed worsening chest pain. An echocardiogram revealed a large pericardial effusion with cardiac tamponade. She was taken for an emergent open pericardial window placement to relieve cardiac tamponade, where 600 mL of blood was drained. Considering the timeline of the development of a large bloody pericardial effusion following initiation of apixaban, spontaneous hemorrhagic cardiac tamponade attributed to the use of apixaban was diagnosed. The patient was eventually taken off all anticoagulants. In considering potential mechanisms, impaired hepatic and renal metabolism of apixaban could be factored in this case. In addition, CKD can increase bleeding risk, due to platelet dysfunction and impaired interaction of von Willebrand factor with GPIIb-IIIa. Moreover, renal secretion of apixaban is mediated by p-glycoprotein and amiodarone is an inhibitor of this protein. Although extremely rare, spontaneous hemorrhagic cardiac tamponade can occur with the use of DOACs, such as apixaban. Prompt recognition and urgent treatment remain keys to avoiding adverse patient outcomes.

Management of a Traumatic Penetrating Cardiac Injury in a Low-Resource Center Without a Cardiothoracic Surgery Department

Traumatic penetrating cardiac injury is a rare pathology with a high mortality rate, more commonly occurring in a military setting or during violent assaults in a civilian environment. Given the anatomy, these injuries are often managed by cardiothoracic surgeons. However, in an institute that lacks these specialists, the responsibility for managing this condition falls on the shoulders of the general surgeon on call. We herein report a case where a penetrating cardiac injury was managed successfully by general surgeons in the absence of cardiothoracic surgeons. This case serves two educational purposes. The first is that Caribbean hospitals possess the potential to match a developed country's medical standard if additional resources can be obtained from their respective governing bodies. The second is that a general surgeon's role is not yet finished in the modern era of sub-specialization, especially in a setting that lacks dedicated specialists.

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.

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.

Congenital Atrial Septal Defect Presenting With Tamponade Physiology and an Associated Viral Illness

Cardiac tamponade is a serious clinical syndrome that often presents with the classic triad of hypotension, jugular vein distention and diminished or muffled heart sounds on auscultation (Beck's Triad). This phenomenon occurs due to fluid accumulation in the pericardial space which compresses the heart, reduces cardiac output and may cause cardiogenic shock. In this report, we present a case of a 22-year-old female with a congenital atrial septal defect (ASD) and right ventricular failure with tamponade physiology with an associated viral illness.

Point of care ultrasonography in onco-nephrology: A stride toward better physical examination

Onco-Nephrology is an emerging subspecialty of Nephrology that focuses on a broad spectrum of renal disorders that can arise in patients with cancer. It encompasses acute kidney injury (AKI), complex fluid, electrolyte, and acid-base disorders, as well as chronic kidney disease caused or exacerbated by cancer and/or its treatment. In many such scenarios including AKI and hyponatremia, objective evaluation of hemodynamics is vital for appropriate management. Point of care ultrasonography (POCUS) is a limited ultrasound exam performed at the bedside and interpreted by the treating physician intended to answer focused clinical questions and guide therapy. Compared to conventional physical examination, POCUS offers substantially higher diagnostic accuracy for various structural and hemodynamic derangements. In this narrative review, we provide an overview of the utility of POCUS enhanced physical examination for the Onconephrologist supported by the current evidence and our experience-based opinion.

Pediatric Pericarditis: Update

PURPOSE OF REVIEW

While there have now been a variety of large reviews on adult pericarditis, this detailed review specifically focuses on the epidemiology, clinical presentation, diagnosis, and management of pediatric pericarditis. We have tried to highlight most pediatric studies conducted on this topic, with special inclusion of important adult studies that have shaped our understanding of and management for acute and recurrent pericarditis.

RECENT FINDINGS

We find that the etiology of pediatric pericarditis differs from adult patients with pericarditis and has evolved over the years. Also, with the current COVID-19 pandemic, it is important for pediatric clinicians to be aware of pericardial involvement both due to the infection and from vaccination. Oftentimes, pericarditis maybe the only cardiac involvement in children with COVID-19, and so caregivers should maintain a high index of suspicion when they encounter children with pericarditis.  Large-scale contemporary epidemiological data regarding incidence and prevalence of both acute and recurrent pericarditis is lacking in pediatrics, and future studies should focus on highlighting this important research gap. Most of the current management strategies for pediatric pericarditis are from experiences gathered from adult data. Pediatric multicenter trials are warranted to understand the best management strategy for those with acute and recurrent pericarditis.

CASE VIGNETTE

A 6-year-old child with a past history of pericarditis almost 2 months ago comes in with a 2-day history of chest pain and fever. Per mother, he stopped his steroids about 2 weeks ago, and for the last 2 days has had a temperature of 102F and has been complaining of sharp mid-sternal chest pain that gets worse when he lies down and is relieved when he sits up and leans forward. On examination, he is tachycardic (heart rate 160 bpm), with normal blood pressure for age. He appears to be in pain (5/10), and on auscultation has a pericardial friction rub. His lab studies are notable for elevated white blood cell count and inflammatory markers (CRP and ESR). His electrocardiogram reveals sinus tachycardia and diffuse ST-elevation in all precordial leads. His echocardiogram demonstrates normal biventricular function and a trace pericardial effusion. His cardiac MRI confirms recurrent pericarditis. He is started on indomethacin and colchicine. He has complete resolution of his symptoms by day 3 of admission and is discharged with close follow-up.

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).

Postsurgical Left Atrial Compression due to Hemopericardium Resulting in Liver Failure: A Rare Cause of Cardiac Tamponade

• Postoperative pericardial effusion may cause left-sided chamber compression. • Focal left-sided cardiac tamponade may present with atypical clinical or echo findings. • Focal tamponade can result in acute liver failure post–cardiac surgery.

Comparison between Emergency Severity Index and Heart Failure Triage Scale in heart failure patients: A randomized clinical trial

BACKGROUND

It is not clear whether Emergency Severity Index (ESI) is valid to triage heart failure (HF) patients and if HF patients benefit more from a customized triage scale or not. The aim of study is to compare the effect of Heart Failure Triage Scale (HFTS) and ESI on mistriage among patients with HF who present to the emergency department (ED).

METHODS

A randomized clinical trial was conducted from April to June 2017. HF patients with dyspnea were randomly assigned to HFTS or ESI groups. Triage level, used resources and time to electrocardiogram (ECG) were compared between both groups among HF patients who were admitted to coronary care unit (CCU), cardiac unit (CU) and discharged patients from the ED. Content validity was examined using Kappa designating agreement on relevance (K*). Reliability of both scale was evaluated using inter-observer agreement (Kappa).

RESULTS

Seventy-three and 74 HF patients were assigned to HFTS and ESI groups respectively. Time to ECG in HFTS group was significantly shorter than that of ESI group (2.05 vs. 16.82 minutes). Triage level between HFTS and ESI groups was significantly different among patients admitted to CCU (1.0 vs. 2.8), cardiac unit (2.26 vs. 3.06) and discharged patients from the ED (3.53 vs. 2.86). Used resources in HFTS group was significantly different among triage levels (H=25.89; df=3; P<0.001).

CONCLUSION

HFTS is associated with less mistriage than ESI for triaging HF patients. It is recommended to make use of HFTS to triage HF patients in the ED.

Traumatic retrosternal hematoma leading to extra-pericardial cardiac tamponade-Case report

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Mediastinal hematoma caused by sternal fracture leading to cardiac tamponade it’s a rare presentation.

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CT Scan it’s an effective method to diagnose mediastinal hematoma.

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High clinical suspicion of extra pericardial tamponade is required when sternal fracture associated with mediastinal hematoma.

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The best management for mediastinal hematoma its urgent evocation of the hematoma to decrease the pressure on the heart.

Introduction

Cardiac tamponade typically results from fluid or gas collection in the pericardial space leading to impairment in the cardiac function.

Presentation of case

A 34 years old male patient presented to the ER after a fall from height. X-rays were done which showed no hemothorax or pneumothorax and multiple stable pelvic fractures. Computed tomography (CT) scan for trauma was done after stabilizing the patient and showed sternal fracture with a huge retrosternal hematoma. The patient was intubated immediately, and an Echocardiogram was ordered along with preparation to go to the operation room urgently due to high suspicion of a rare case of cardiac tamponade. but the patient had cardiac arrest and couldn't be revived despite the CPR effort.

Discussion

This is a very unusual presentation of cardiac tamponade, mediastinal hematoma leading to extra pericardial tamponade. CT scan is an effective method to diagnose extra pericardial tamponade. In addition, to the high clinical suspicion is required. The sole treatment of mediastinal hematoma is an urgent evacuation.

Conclusion

A careful assessment with high clinical suspicion along with CT Scan is the best way to diagnose extra pericardial tamponade cause by sternal fracture.

Swinging heart caused by diffuse large B-cell lymphoma

Pericardial disease is a common complication of solid tumors and occasionally seen in hematologic malignancies. Pericardial effusion, when it occurs, is usually caused by tumor seeding of the pericardium leading to a serous effusion or by mass effect from mediastinal lymphadenopathy blocking drainage of lymphatic ducts. Pericardial disease from non-Hodgkin's lymphoma is uncommon and malignant pericardial effusion is even rarer. Here we present a case of a 31-year-old male with diffuse large B-cell lymphoma who developed cardiac tamponade from a malignant pericardial effusion.