Saturday, June 10, 2017

A patient with shortness of breath

This 50-something with a history of alcohol abuse complained of 2 weeks of increasing dyspnea for 2 weeks, with some chest pain and cough.  She was not ill-appearing.

Her BP was 111/68, with a heart rate of 117, RR 22, Temp 36.4 C and SpO2 of 95%.

She had a routine ECG performed at triage, as we do with all patients who are SOB.
What do you think?





















I was brought this ECG and asked what I thought.

I responded: there is very low voltage and tachycardia, does the ultrasound show an effusion?

Here is the ED point of care ultrasound:

There is a huge effusion with collapse of the RV.  This is diagnostic of tamponade.


A pigtail catheter was placed and over 600 mL of serosanguinous fluid was drained.

Without going into details, she not surprisingly turned out to be much sicker than she initially appeared.

Low Voltage:

Defined as:

1.  less than 5 mm of QRS amplitude in limb leads
2.  less than 10 mm of QRS amplitude in precordial leads

Etiologies:

Fluid: pericardial effusion and pleural effusion
Fat: Obesity
Air: Emphysema or pneumothorax
Infiltrative disease: Amyloidosis, Myxedema, Sarcoid, Hemochromatosis
Loss of Viable Myocardium: Old MI, especially in multiple locations; Nonspecific dilated cardiomyopathy


6 comments:

  1. Great case! One thing to point out is that most physicians think tamponnade patients look awful. They don't!!! We see post op cardiac surgery patients coming back in tamponade all the time and they most often don't look very sick (just a bit tachycardic)!

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  2. Other causes: Dextrocardia, Implantat, Endomyocardial fibrosis

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  3. What is result of precordial analysis fluid and what si underline cause,is there any clinical sign of tamponDe clear on bedside clinical exam ?? Thanks for great weekly cases

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  4. are you doing the pigtail or sending it to IR?

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