Emergency Department Diagnosis of Pericardial Tamponade Aided by Goal-directed Bedside Echocardiography

Case Presentation

A 25-year-old male with a history of common variable immunodeficiency and suboptimal compliance with monthly intravenous gamma globulin therapy presented to the emergency department (ED) with a week-long history of pleuritic chest pain and shortness of breath. His symptoms had been increasing in severity, which prompted him to seek medical care. On initial exam, the patient’s vital signs were unstable, with a heart rate of 130 beats/minute, a systolic blood pressure ranging from 80 to 90 mm Hg, and a respiratory rate of 20 to 25 breaths/minute. Despite a 2-L normal saline bolus, he remained unstable. An electrocardiogram showed evidence of pericarditis (Figure 1). Goal-directed bedside echocardiography performed by the treating emergency physicians (EPs) showed a large pericardial effusion (Figure 2; Video Clip S1 [parasternal long] and Video Clip S2 [parasternal short], available as supporting information in the online version of this paper). Right ventricular collapse was identified, as well as a swinging motion of the heart within the pericardial space. Both of these echocardiographic findings are signs of a hemodynamically significant pericardial effusion.¹ When the echocardiographic signs were combined with the patient’s clinical status, cardiac tamponade was diagnosed. Cardiology was immediately consulted, and the patient was taken to the cardiac procedure lab for emergent pericardiocentesis, during which 700 mL of milky yellow fluid was removed from the pericardial space. Blood and pericardial fluid cultures grew β-lactamase–positive Haemophilus influenzae. The patient was treated with intravenous antibiotics, recovered fully, and was discharged home. In a randomized controlled trial, Jones et al.² demonstrated that bedside goal-directed ultrasound in ED patients with hypotension can significantly reduce the number of differential diagnoses and increase the likelihood that the EP has identified the correct diagnosis within the first 15 minutes of evaluation and treatment. The video clips provide visual reinforcement of this modality’s usefulness in the hypotensive ED patient.

Figure 1.  Electrocardiogram demonstrating pericarditis.

Figure 2.  Still image from echocardiogram showing large pericardial effusion.