Tamponade Uncovered: The Life-Saving Role of POCUS in a Haemodynamically Unstable Visitor

By Dr Steve Korbel, South Eastern Sydney Local Health District

A 63 yr old lady presented to ED with a friend with shortness of breath. She was visiting from Vietnam, and had recently seen a GP who had commenced her on antibiotics for a cough, however her shortness of breath was worsening.

She had no significant past medical history and was on no medication. She had no chest pain, and no previous cardiac history.

One of our registrars was treating her for possible congestive cardiac failure when I came onto my shift at 2pm. She was being managed in our resuscitation room due to low blood pressure and worsening shortness of breath.

Due to her having no previous cardiac history, when I came on shift we decided to do a bedside cardiac ultrasound.

This revealed a very large pericardial effusion, with sonographic signs of cardiac tamponade. Cardiology were consulted and were coming down to review the patient in the ED.

The patient rapidly deteriorated prior to their arrival – her blood pressure dropped to SBP64, and she became drowsy.

Therefore, we elected to drain her pericardial effusion in ED.

I used a subcostal approach with a pericardiocentesis kit, and we drained 150mls of blood stained fluid and then I inserted a pericardial drain using a seldinger technique.

Her blood pressure improved nearly immediately, and later that evening she was sitting up, talking and eating dinner.

She had a CT aortogram and CT chest/abdo/pelvis to exclude aortic dissection and to look for any evidence of malignancy. She was admitted under cardiology to ICU, and drained a total of 1.4 L of fluid from her pericardial effusion. The CT showed no evidence of aortic dissection, but did show a lung mass, and the pericardial fluid cytology was positive for malignancy (likely lung adenocarcinoma). She improved quickly, and was discharged from ICU into the care of medical oncology for further treatment of her previously undiagnosed cancer.

In this case, POCUS was truly lifesaving, as well as vital for diagnosis.

Corresponding video clips: Intially showing the pericardial effusion and tamponade, and then with the pericardial drain in situ.

Measurement of the pericardial effusion.

a4c view (apical 4 chamber view) showing pericardial effusion and tamponade

plax view (parasternal long axis view) showing pericardial effusion and tamponade

plax view (parasternal long axis view) with the drain in situ

psax view (parasternal short axis view) with the drain in situ