ALLAN WHITEHEAD
EMERGENCY PHYSICIAN BASS COAST HEALTHCCPU (OTAGO) CCPU (ASUM)
46yo male sent to ED as a result of having a routine pre-op ECG at a pathology laboratory organised by his GP which showed some non-specific changes on a background of a mild electric shock 5/52 earlier which he did not have LOC nor seek medical attention. Patient discussed by the GP with a Cardiologist for patient to attend ED and for a possible echo.
We don’t have an echo service at our small hospital (neither GP or Cardiologist rang us to discuss the patient) but I happened to be on duty when the patient arrived after driving himself to hospital
Patient had slurred speech and a PEG due to resection 10 months earlier of an oral cavity cancer by ENT and plastics at the nearest tertiary centre.
There was more surgery planned so he was asked to have a pre-op ECG.
Not having radioRx or chemoRx.
Feeling well, not dizzy or SOB and no current chest pain.
Reported intermittent brief nocturnal bilateral anterior chest pain and separately intermittent left anterior neck pain in last 5/52 since electrocution.
Well-looking SBP 120 HR 100 SR no respiratory distress O2sat 97% on air.
Afebrile, no evidence of DVT.
ECG: ST elevation V3-V4 (but V4 alone was elevated on ECG at path 4hrs earlier), istat Trop I/U&E/Cr: NAD
Decided to do a focussed cardiac US in case he had a pericardial effusion.
Using my GE Vscan showed a large pericardial effusion causing slight RA free wall collapse, with a large RV mass occupying ¾ of RV cavity with slight MR and a distended IVC. No flow in the mass but appears to be a tumour rather than clot.
Discussed with Cardiothoracic Reg at tertiary centre. Advised to do a CTPA as may help determine whether RV mass is clot or tumour so whether he should be given heparin
CTPA confirmed US findings: large pericardial effusion with 4.5-5cm diameter mass in RV. Also has a 13mm diameter pericardial nodule and multiple lung nodules and mediastinal lymphadenopathy suspicious for metastatic disease. Given absence of PE the RV mass is almost certainly tumour as well.
Patient transferred to tertiary centre.
I then met him in our hospital car park 6/52 later and he looked well and reported no pericardial drain or biopsy had been performed and he had immunotherapy and responded well so discharged after 2/52 inpatient admission