Emergency Bedside Ultrasound Diagnosis of Nontraumatic Cardiac Tamponade—A Case of Type A Aortic Dissection

A 50-year-old male smoker presented to the emergency department by emergency medical services. He was found down in a home where he was working to repair a heater. He arrived weak and diaphoretic complaining of midline chest pain and dyspnea. Initial assessment revealed tachycardia, hypotension (blood pressure 91/58 mm Hg in left arm and unable to obtain a pressure in the right arm), and plethora of the head and neck. Electrocardiogram was nondiagnostic. Bedside cardiac ultrasound showed a large pericardial effusion with right ventricular collapse consistent with cardiac tamponade (Figure 1 and Video Clip S1, available as supporting information in the online version of this paper). The patient was stabilized with aggressive hydration and taken for a computed tomography scan for a dissection protocol (Figure 2). It revealed a Type A aortic dissection from the level of the aortic root to the left subclavian artery. Also noted was severe hemopericardium with tamponade physiology. The patient was taken to the operating room, where a finger-sized hole in the aorta was discovered just adjacent to the right coronary artery. Operative repair was successfully completed and the patient made a full recovery and was discharged home 1 week later.

Figure 1.  Subxiphoid view of the heart. E = pericardial effusion; LV = left ventricle; RV = right ventricle; arrow = right ventricular collapse.

Figure 2.  Contrast-enhanced computed tomography scan. E = pericardial effusion; Ao = aorta; LA = left atrium; arrow = dissection flap of ascending aorta.