Clinical case 14 – Pericardial tamponade away from home

26 Nov

The case…

A 24 year old West African man presents to the ED in Liberia with a one month history of night sweats, weight loss and increasing shortness of breath on exertion. He was markedly dyspnoeic while at rest. His vital signs are: HR 105/min, RR 26/min, O2 sats 90%, BP 85/55mmHg. He had reduced air entry to both lung bases with dullness to percussion bilaterally, a raised JVP and inaudible heart sounds

What we did…

A bedside ultrasound showed a large pericardial effusion and bilateral pleural effusions. On detailed assessment of the images, early diastolic RV collapse and a plethoric IVC were noted, indicating tamponade physiology. The ultrasound findings, taken in conjunction with his recent deterioration in clinical condition, prompted ultrasound-guided pericardiocentesis as an emergency procedure. A subcostal approach was chosen, and 800ml of straw-coloured fluid was drained from the pericardial space. There was an immediate clinical improvement, with a significant increase in his blood pressure, oxygen saturations and a reduction in his heart rate.

Post procedure ECHO showed a return to normal function of the heart, with an absence of RV diastolic collapse. The pericardial fluid was sent for GeneXpert, which was positive for Mycobacterium Tuberculosis, so a diagnosis of disseminated Tuberculosis was made and he was started on therapy and discharged from hospital two weeks later

The images…

PLAX shows a large circumferential pericardial effusion

M mode at the mitral valve shows that RV is collapsed when the mitral valve is open (diastole) indicating tamponade physiology

Subcostal window showing plethoric IVC (this is highly sensitive for tamponade)

Subcostal views post aspiration of pericardial fluid – this is a much healthier, comfortable looking heart!

FOAMed resources

A bit about Callum :

I’m an Emergency Medicine trainee based in Dublin who has a passion for POCUS and for working in remote and low resource settings; whether that’s up a mountain in the Himalayas or in a Liberian emergency department. The latter is where he first discovered the huge array of uses for POCUS and the remarkable impact it can have on patient care, and he is delighted to join the growing group of doctors expanding it’s use in Ireland. Stay tuned for more fantastic cases from Callum!

Proofread – Cian McDermott

@Callum_Swift 

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