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sequential sinister sightings…

the case.

a 68 year old male presents to ED with left-sided pleuritic chest pain & shortness of breath. He is tachycardic, but normotensive (142 systolic) with room air saturations of 93%.On further questioning, he has no significant past medical history except that he smokes “too many” cigarettes.

This is his ECG…

LungCa&Tamponade

[DDET Describe & interpret his ECG…]

  • Rate.
    • 115 bpm
  • Rhythm.
    • Regular [sinus]
  • Axis.
    • ~ -11* [normal]
  • Intervals.
    • PR ~ 200 msec
    • QRS ~ 80 msec
    • QTc ~ 430 msec
  • Segments.
    • Isoelectric ST’s
  • Others.
    • Low-voltage
      • Precordial leads < 10mm
      • No electrical alternans.
    • Poor R-wave progression
    • Wandering baseline
    • Artefact – V4.

Interpretation.

Sinus tachycardia with low-voltage QRS &  borderline first-degree heart block.

What are the differential diagnoses in this case ??
Check out LOW QRS VOLTAGE @ LifeInTheFastLane.com

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[DDET What about his CXR ?]

Pleuritic CP & dyspnoea

 

Does this help ?
I think it does… well it did on the day !!

The concern…

Well circumscribed, rounded, soft-tissue density lesion in the right lower lobe.
Well circumscribed, rounded, soft-tissue density lesion in the right lower lobe.

With a suggestion of a new lung lesion associated with pleuritic chest pain & hypoxia, the diagnosis of PE was chased & a CTPA ordered…

[/DDET]

[DDET Click here for the CT images…]

Confirmation of right lung malignancy. No evidence of pulmonary embolism.
Confirmation of right lung malignancy. No evidence of pulmonary embolism.

The CT however does carry another sinister finding…

httpv://www.youtube.com/watch?v=z1N-cxtJ0wU

[/DDET]

[DDET You take the ultrasound to the bedside…]

Parasternal long axis…

httpv://www.youtube.com/watch?v=Ju35LxUPkr0

Apical four chamber…

httpv://www.youtube.com/watch?v=zZaKRvYXYXM

Subxiphoid view…

httpv://www.youtube.com/watch?v=bsyVjJCDsOM

[/DDET]

[DDET The Diagnosis]

Cardiac Tamponade.

[/DDET]

[DDET How do we make this diagnosis ?]

Beck’s Triad.

  1. Hypotension
  2. Distended jugular veins
  3. Muffled (distant) heart sounds

Pulsus Paradoxus.

Pulsus paradoxus occurs in many pathologic conditions [eg. PE, RV infarct, asthma & tension PTx]. This is a clinical spectrum (not an absolute “on & off” phenomena).

In the presence of a pericardial effusion, it is suggested that pulsus paradoxus of >10mmHg helps distinguish those with tamponade from those who do not !!

Cardiac Tamponade by ECHO.

  • RV collapse in diastole
Right ventricular collapse (arrows) on subxiphoid view.
Right ventricular collapse (arrows) on subxiphoid view.
  • RA collapse in systole
Diastolic collapse of right atrium.
Diastolic collapse of right atrium.
  • Pulsus paradoxus on TV/MV inflow
Mitral valve inlet velocities (measured by pulse-wave doppler through MV in A4C view). Velocity variation > 25% suggests tamponade.
Mitral valve inlet velocities (measured by pulse-wave doppler through MV in A4C view). Velocity variation > 25% suggests tamponade.
  • IVC dilatation
Plethoric IVC without respiratory variation
Plethoric IVC without respiratory variation

Putting it together with ECHO…

Large pericardial effusion with features of tamponade. A, A4C of LV, LA, and RV that shows large PE with diastolic right-atrial collapse (arrow). B, M-mode image with cursor placed through RV, IVS, and LV in parasternal long axis. The view shows circumferential PE with diastolic collapse of RV free wall (arrow) during expiration. C, M-mode image from subcostal window in same patient that shows IVC plethora without inspiratory collapse. IVC, inferior vena cava; IVS, interventricular septum; LA, left atrium; LV, left ventricle; PE, pericardial effusion; RV, right ventricle. (From Troughton RW, Asher CR, Klein AL: Pericarditis. Lancet 2004;363:717–727.)
Large pericardial effusion with features of tamponade. A, A4C with diastolic right-atrial collapse (arrow). B, M-mode image showing circumferential PE with diastolic collapse of RV free wall (arrow) during expiration. C, M-mode image showing IVC plethora without inspiratory collapse. (From Troughton RW, Asher CR, Klein AL: Pericarditis. Lancet 2004;363:717–727.)

[/DDET]

[DDET The outcome…]

Despite evidence of RV collapse & clinical pulsus paradoxus, our patient maintains normotensive.

He is taken to the interventional suite by our Cardiologists for pericardial drainage.

Cytology confirmed non-small cell lung cancer.

[/DDET]

[DDET References]

  1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
  2. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition.
  3. Roy CL et al. Does this patient with a pericardial effusion have cardiac tamponade? JAMA. 2007 Apr 25;297(16):1810-8.
  4. Swami A & Spodick DH. Pulsus Paradoxus in Cardiac Tamponade: A Pathophysiologic Continuum. Clin. Cardiol. 2003. 26, 215–217.
  5. Troughton RW, Asher CR, Klein AL: Pericarditis. Lancet 2004;363:717–727.
  6. Goodman A, Perera P, Mailhot T, Mandavia D. The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade. J Emerg Trauma Shock 2012;5:72-5
  7. Pocket Atlas of Echocardiography.
  8. Tamponade. Echocardiography in ICU – Stanford University.
  9. Pericardial Tamponade – Ultrasound Podcast

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