While working at a teaching hospital in Haiti, a patient in her 30s presented to the ED with altered mentation. Upon initial evaluation, the patient appeared to be very sick. The residents, who have embraced point of care ultrasound as a diagnostic tool, quickly noted that she had free fluid in her abdomen, pleural cavity, and pericardium. Given the prevalence of Tuberculosis +/- HIV/AIDS, it was thought that extra pulmonary tuberculosis was the likely etiology of her presentation.

Free fluid in the abdomen. Similar findings were noted in the pleural space.

On further evaluation of her heart using point of care ultrasound, she had significant diastolic collapse of the right ventricle in the setting of a very significant pericardial effusion; this is consistent with tamponade. Although she was tachypneic and tachycardic in the 120s and ill appearing, the patient’s blood pressure remains in the 140s systolic.

PSL view of the heart with diastolic collapse of the RV.

Discussion:

In low resource settings, in a patient population where HIV/TB is prevalent, the Focus Assessment with sonography for HIV-associated tuberculosis (FASH) is a good tool to use for the assessment of patients that are presenting to the emergency department in critical condition. 1 Ultrasound can help solidify the diagnosis of extra pulmonary TB. Furthermore, if fluid is seen in any of the cavities, diagnostic testing can be performed to aid in the diagnosis.

With the ultrasound findings that we had in this fairly young patient, TB certainly had to be highly considered. Furthermore, in a patient who is unstable, ultrasound help us to find areas where steps can be taken to provide life saving care. In this case, the patient did benefit from bilateral thoracentesis which did improve her respiratory status.

On ultrasound, it is clear that the patient has findings concerning for tamponade. This is sometimes referred to as pre-tamponade, due to the absence of hypotension which is part of the classic triad that is used to diagnose cardiac tamponade. Regardless of what you choose to call it, I do think that an individual with diastolic collapse of the RV in the setting of a large pericardial effusion need to be looked at very carefully. A patient who only has ultrasound findings of tamponade may not necessarily need a pericardiocentesis to be performed in the next 30 seconds; but, this is a patient that is to be monitored extremely closely.

Beck’s triad of hypotension in the absence of hypovolemia, jugular venous distention, and muffled heart sounds is certainly useful for the diagnosis of tamponade. Now, there are a few things to take note of. The first is the fact that this classic definition of cardiac tamponade is from Beck’s description in the 1930s. Beck actually described two types of tamponade: chronic tamponade and acute tamponade. For chronic tamponade, the diagnostic triad of JVD, ascites, and a small quiet heart was used. For acute tamponade, Beck’s description include JVD, hypotension, and muffled heart sound; these 3 are what is currently referred to as Beck’s triad.  The second is that only 1/3 of patients with acute tamponade has the classic triad and up to 10% of patients may not have any of those findings. The 3rd thing to note is that even when all 3 signs are present, they are usually followed by cardiac arrest. They may be great for making the diagnosis, but not so useful for changing the prognosis. Furthermore, there are reported cases of patients in cardiac tamponade who actually presented with hypertension, which resolved once pericardiocentesis was performed.

With ultrasound being readily available, it is important that it is used early in the acutely ill patient. Ultrasound help us to see findings consistent with tamponade earlier. When the diagnosis of tamponade is made on ultrasound in the absence of Beck’s triad, we may simply be catching the disease process at an earlier time point; this may actually give us the opportunity to change the patient’s outcome. As you can see in the previous paragraph, it is not as clear as we may sometimes think; it is important that you evaluate your patient carefully and think of what may happens in the next 10 minutes or 2 hours. Sending the patient to the elevator may  not always be the best course of action.

For our patient, once the diagnosis was made, we had to decide on the next step. The patient did not appear to be collapsing from a hemodynamic standpoint and was somewhat stable to tolerate transport for drainage to be done by cardiology. However, cardiology was not available. We alerted the medicine team (I am not sure why) who were rightfully not comfortable with taking this critical patient and no ICU bed was available. This made the decision very easy (from a political standpoint); the only way to prevent the patient’s condition from worsening was to do the pericardiocentesis. With ultrasound guidance, I felt that the safest step for the patient was for the procedure to be performed in the ED; and, I did feel that my ED team was at least equally capable of managing the patient at that point. While it is important for ED providers to understand our limitations, we also have to be comfortable with the idea of being the best at providing emergency treatment for deadly conditions.

Pre-procedure, this PSL view using the linear probe. Look at how well the structures are visualized using the linear probe.

Using ultrasound guidance, we used an in plane approach in the parasternal long view and were able to remove a large quantity of fluid with resolution of the diastolic collapse. Classically, the procedure was done using the subcostal approach. However, with ultrasound guidance, the standard approach is the one that gives you the most direct access to a large pocket of fluids in the pericardium. In this patient, the abdomen was full of free fluid and it would be nearly impossible to use the subcostal approach to get to the effusion.

I do not see any reports of a linear probe being used for pericardiocentesis. We were able to see clearly where we needed to go, including a clear visualization of the myocardium. Furthermore, using the high frequency probe, we were able to better visualize the needle which helped in decreasing the risk of complications. An 18 gauge intracatheter (typical IV starting catheter) was used because that is all that we had and it worked very well. Of course, we were not able to leave a pigtail in the pericardium for continuous drainage.

The above clip is showing the procedure being performed using a linear high frequency probe.  At this point, the needle has been removed and the catheter tip is in the pericardial cavity. A bubble test was also performed which confirmed proper placement.

While performing pericardiocentesis, some complications to consider are punctures of the ventrical or atrium, injury to the coronary /internal mammillary/neurovascular bundle, and pneumothoraces.

Take home points:

In a critical patient presenting to the ED, ultrasound is a fast and inexpensive modality that can be used for diagnosis and management. It can help us to provide lifesaving treatment emergently. In low resource settings, it may be the only modality available.

In areas where TB is prominent, it must always be in the differential diagnosis. It is reported that 20% of those patient presents with EPTB (which is not transmitted by respiratory droplets). The FASH protocol can be applied.

Using POCUS, we may be able to diagnose cardiac tamponade before the development of clinical findings that are highly associated with mortality.  Also, ultrasound findings may push us to look more carefully for other signs that could be missed in a noisy ED.

Sinus Tachycardia is seen in most cases of cardiac tamponade. The classic triad is only seen in 1/3 of patient and is usually followed by cardiac arrest.

Pericardiocentesis should be performed with ultrasound guidance. It is a reasonably safe procedure when proper techniques are applied. The anatomy, including the coronary vessels, should be considered.

 

  1. Heller T, Wallrauch C, Goblirsch S, Brunetti E. Focused assessment with sonography for HIV-associated tuberculosis (FASH): a short protocol and a pictorial review. Crit Ultrasound J. 2012;4(1):21. doi:10.1186/2036-7902-4-21.
  2. Reardon RF, Laudenbach A, Joing SA. Cardiac. In: Ma JO, Mateer JR, Reardon RF, Joing SA, eds. Ma and Mateer’s Emergency Ultrasound. 3rd edition. McGraw-Hill Education; 2014.
  3. Mallemat HA, Tewelde SZ. Pericardiocentesis. In: Roberts, James R., Catherine B. Custalow, Todd W. Thomsen, and Jerris R. Hedges. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 2014.
  4. Tsang TS, Freeman WK, Sinak LJ, Seward JB. Echocardiographically guided pericardiocentesis: evolution and state-of-the-art technique. Mayo Clin Proc. 1998;73(7):647-652. doi:10.1016/S0025-6196(11)64888-X.
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