“Help me, my chest hurts!”

October 2018 – CASE 1

Each month, I will be featuring an ultrasound done by one of our fellows our faculty.

This month is brought to you by one of our third year PEM fellows!

Healthy 18 year old male presented with chest pain and chest tightness. On initial exam he was labored and tachypnic. There was initial concern for possible pneumothorax so a bedside ultrasound was performed. Normal lung sliding was seen, followed by these images. What do you see?

VS: T 36.9, HR 113, RR 24, BP 106/65, PO2 100% RA

 

 

Scroll down for answer

ANSWER

Pericardial Effusion.

The effusion was diagnosed within 5 minutes of the patients arrival and is a great example how POCUS changed this patient’s management.

He was admitted to the PICU with concern for tamponade physiology and underwent pericardiocentesis and drain placement.

 

 

 

Want more information and resources? Read more below and check out these sites:

Pericardial effusions and Tamponade on Bedside Ultrasound

Point-of-care ultrasonography can assist in the evaluation of patients in distress. Often the classic physical exam findings of tamponade are not present (Beck’s triad: JVD, muffled heart sounds and hypotension).

Emergency physicians detect pericardial effusions on bedside ultrasound with a sensitivity of 96%, specificity of 98%, and overall accuracy of 97.5%.

What findings are seen on ultrasound with tamponade physiology?

Increased pressure resulting from the effusion within the pericardial sac inhibits adequate filling during diastole in return causing right atrial and ventricular collapse.

The earliest and most sensitive sign of tamponade is right atrial collapse. Right ventricular collapse can also be seen and is more specific but less sensitive for tamponade. Evaluating for diastolic collapse versus systole should be done in the parasternal long view using M mode. The axis should be placed through theright ventricular free wall and the mitral valve. In tamponade, the right ventricular free wall moves inward (paradoxically) toward the septum when the mitral valve opens.

Evaluation of the IVC can also aid in the diagnosis. A plethoric IVC that does not exhibit respiratory variation can be seen.

Ultrasound use in pericardiocentesis 

Pericardiocentesis without the use of ultrasound has been shown to have complication rates as high as 50%.US guided pericardiocentesis is now the standard-of-care and has reduced morbidity and increased success rates (4.7% and 97% respectively).2,3 

 

Examples of tamponade:

 

Ultrasound Gel Podcast:

https://www.ultrasoundgel.org/?search=pericardial+effusion

References:

  1. Mandavia DP, Hoffner RJ, Mahaney K, et al. Bedside echocardiography by Emergency Physicians. Ann Emerg Med. 2001;38(4):377-82.
  2. Tsang TS, Freeman WK, Sinak LJ, et al. Echocardiographically guided pericardiocentesis: evolution and state-of-the-art technique. Mayo Clin Proc. 1998;73(7):647-52.
  3. Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77(5):429-36.

 

 

 

Laurie Malia

Laurie Malia

Assistant Professor of Emergency Medicine and Pediatrics,Pediatric Emergency Medicine Ultrasound Fellow at Morgan Stanley Children's Hospital /Columbia University Medical Center Department of Emergency Medicine
PEM doc; POCUS; Pediatrics; Healthcare equality
Laurie Malia

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Laurie Malia

Laurie Malia

PEM doc; POCUS; Pediatrics; Healthcare equality