The case
An 80 year old female complained of chest pain 5 days prior to attendance. She lived alone and did not want to leave the house late at night and did seek medical attention.
On the day of presentation she had a witnessed collapse in a supermarket with no apparent preceding symptoms. EMS found her in PEA with no bystander CPR. ACLS was commenced and she was transferred to ED.
40 mins post arrest she arrives in ED and remains in PEA. She is placed on a LUCAS device and during pulse check the following image is obtained.
This is a sub-xiphpoid or sub costal view. In this case the orientation is reviersed. It is often the easiest view to obtain during cardiac arrest.
There is a large echogenic pericardial effusion surrounding the heart. The ventricles appear open but there is only a tiny twitch of movement at the apices.
Pericardial effusion in cardiac arrest
- traumatic, possibly from CPR
- aortic dissection
- ventricular free wall rupture
[collapse]
It was initially thought that the pericardial effusion was from trauma of the CPR (there was significant chest wall injury evident) and given the prolonged down time without response and advanced age and lack of active cardiac contraction resuscitation was ceased.
On post mortem there was a ventricular free wall rupture with evidence of recent trans mural MI (within the past week) at the site of rupture.
Read more on free wall rupture over at Dr Smith’s ECG blog.
Below are some further views obtained
Great case and explanations guys – keep up the good work!
Very interesting. Pericardial effusions are not usually that echogenic, right? They are usually more of a black line. I guess in this case it was because the blood had been there for a good while.
Thanks. Well done on the site
Hi john. You’re right usually always echo free. In this case I imagine it was clotted hence the echogenicity. If the blood was clotted then pericardiocentesis would likely not be useful either. A thoracotomy is an option if you check out Steve smiths blog though it seems a tad extreme for most. Andy
Hi John
The black “hypoechoic” effusions we often see are usually medical – ie. Not blood
Fresh, acute blood in any cavity can appear very echogenic. Most acute haemopericardiums are not black on echo
Common misconception as the teaching echo pics we see are often of more chronic cases
Older blood turns black – fresh blood usually 50 shades of grey
Casey
Can we see the free wall rupture on the first ultrasound image? I see something like a thin part of the ventricle that appears to open with movement.
We didn’t see it ourselves but it may be there in retrospect.
Great post, thanks a lot