So this case was interesting on a couple of levels.
A 76 year old woman presented to the ER with a complaint of abdominal discomfort and was admitted with a diagnosis of pneumonia and lower abdominal cellulitis. She had a history of diabetes, obesity and remote oral cancer which had been treated 6 yrs ago. The next morning, while still in the ER awaiting a ward bed, she had a hypotensive episode, and fortunately the ER doc on shift grabbed an ultrasound probe and took a look, calling me a few minutes later with a diagnosis of tamponade. She was absolutely correct. I saw and echo’d her shortly after:
The first two clips show the IVC, which is distended with minimal variation. This should prompt the bedside sonographer to anticipate downstream pathology (except for iatrogenic volume overload and renal failure…).
The subsequent clips show subxiphoid views (and one clip of the associated left pleural effusion) showing a significant pericardial effusion and difficult to distinguish cardiac chambers.
Clinically, she was dyspneic, uncomfortable, HR 115, BP 130’s systolic (in ER in 80’s then got some fluid). Her heart sounds were not particularly quiet, and her JVP was difficult to assess due to obesity.
Here is the drainage video:
Her abdominal pain resolved very rapidly, her breathing improved and vitals stabilized.
Pathology is still pending, but bloody effusions commonly include malignancy, tuberculosis, but also simple viral paricarditis.
So I think this is a great case for the argument of integrating ultrasound into physical examination rather than as an ancillary test. Because she didn’t present with a predominant hypotensive or respiratory component, the diagnosis wasn’t seriously entertaine, and obesity, body habitus and pleural effusion undoubtedly made physicians overlook the cardiomegaly. However, in my opinion and that of most bedside sonographers, abdominal pain warrants an abdominal us exam, and the distended IVC would have prompted at least a quick cardiac assessment, and the effusion would have been noted immediately.
In my CC/IM practice, hardly anyone escapes the probe, as cardiopulmonary and abdominal status is hardly ever irrelevant to me…
Great case ! Thanks for presenting it. I would have liked to have seen the portion of the clip post-catheter insertion to see what that looks like on the monitor. Looks like we were just getting to that view at the very end ;(
Thanks, will try to find that!
[…] but also pigtail catheter insertion, percutaneous tracheostomy, percutaneous cholecystostomy and pericardial drainage. Because there is a maximum of two residents at any one time, you can expect to have done several […]