What's the diagnosis? By Dr. Sarab Sodhi
A 45 yo male with past medical history of metastatic colon adenocarcinoma presents to the ED with acute on chronic shortness of breath. He looks ill; he has tachycardia, tachypnea and and is hypotensive. Bedside ultrasound is shown. What’s the diagnosis? Scroll down for answer.
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Answer: Cardiac Tamponade
A cardiac emergency, requiring emergent intervention by either the emergency clinician, or if available the interventional cardiologist.
While dogma maintains that tamponade cannot exist if the patient is not hypotensive, this is not true. Tamponade exists in a spectrum, and only severe tamponade results in shock, hemodynamic compromise and death. Moderate and severe tamponade frequently present with just tachycardia. Data suggests that frequently patients are hyper- or normo- tensive.
The anatomy of the heart is shown above. You can identify tamponade from the following markers easily:
RV collapse in diastole (highly specific)
Plethoric IVC (highly sensitive)
More advanced markers can be used (mitral and tricuspid inflow velocities) but the markers above are typically ideal for the novice to even moderately advanced user in most cases.
Kapoor T Locurto M, Farina GA, Silverman R. Hypotension is uncommon in patients presenting to the emergency department with non-traumatic cardiac tamponade. Journal of Emergency Medicine. 2012;42(2):220-226. doi:10.1016/j.jemermed.2010.05.071
Shabetai R.Pericardial effusion: Haemodynamic spectrum. Heart. 2004;90(3):255-256. doi:10.1136/hrt.2003.024810
Hoit BD Pericardial Effusion and Cardiac Tamponade in the New Millennium. Current Cardiology Reports. 2017;19(7). doi:10.1007/s11886-017-0867-5