Question Of The Day #85

question of the day
SS Video 3  Pericardial Tamponade
Which of the following is the most likely cause for this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient presented to the Emergency department with 2 days of shortness of breath without chest pain, cough, or fevers.  The exam shows tachycardia, hypotension, mild tachypnea, clear lungs, and distant heart sounds.  Tension pneumothorax (Choice B) can cause hypotension and tachycardia and COPD is a risk factor for pulmonary bleb formation and rupture.  However, the lungs are equal and clear bilaterally, so this diagnosis is not likely.  Septic shock due to pneumonia (Choice C) is also less likely as there is no fever, the lungs are clear, and the patient lacks a cough.  The ultrasound image given also provides a clear explanation for the patient’s symptoms.  This patient is at risk for pulmonary embolism (Choice A) given his cancer history which can cause a hypercoagulable state and predispose him to clot formation.  Again, an understanding of the ultrasound image will provide the diagnosis.

The ultrasound image is a subxiphoid view of the heart demonstrating a pericardial effusion (red stars) with compression of the right ventricle (yellow arrow). 

This presentation is consistent with cardiac tamponade (Choice D).  Cardiac tamponade is a condition defined by the accumulation of fluid in the pericardial sac to the point of right ventricular collapse and obstructive shock.  Common presenting symptoms of cardiac tamponade include shortness of breath, chest pain, or nonspecific symptoms.  Risk factors for this diagnosis are penetrating chest trauma (hemopericardium), cancer (malignant effusion), lupus, end stage renal disease, uremia, HIV, Tuberculosis, or history of chest radiation.  The presence of hemodynamic instability (hypotension and tachycardia) is a hallmark of this condition, although early stages of tamponade can be seen on cardiac ultrasound before vital signs decompensate.  The patient may have Beck’s triad of muffled distant heart sounds, jugular venous distension, and hypotension, although the majority of patients with cardiac tamponade do not have all three of these signs together.  Treatment involves IV fluids, bedside pericardiocentesis (ultrasound guided preferred), and surgical pericardiotomy (“pericardial window”).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #85," in International Emergency Medicine Education Project, April 22, 2022, https://iem-student.org/2022/04/22/question-of-the-day-85/, date accessed: July 2, 2022

Question Of The Day #67

question of the day
SS Video 2  Large Pericardial Effusion

Which of the following is the most likely cause of this patient’s condition?

This patient arrives in the Emergency Department after sustaining penetrating chest trauma and is found to be hypotensive, tachycardic, and with a low oxygen saturation on room air. The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient’s ultrasound shows fluid in the pericardiac sac which in combination with the patient’s hypotension and tachycardia, this supports a diagnosis of cardiac tamponade.  See the image below for labelling.

Cardiac tamponade is considered a type of obstructive shock.  As with other types of obstructive shock, such as pulmonary embolism and tension pneumothorax, there is a state of reduced preload and elevated afterload.  This causes a reduction in cardiac output (Choice C) which leads to hypotension, tachycardia, and circulatory collapse.  High cardiac preload (Choice A), low cardiac afterload (Choice B), and high cardiac output (Choice D) do not occur in cardiac tamponade.  Treatment for cardiac tamponade includes IV hydration to increase preload, bedside pericardiocentesis, and ultimately, a surgical cardiac window performed by cardiothoracic surgery. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #67," in International Emergency Medicine Education Project, December 10, 2021, https://iem-student.org/2021/12/10/question-of-the-day-67/, date accessed: July 2, 2022

Question Of The Day #54

question of the day
Which of the following is the most likely cause for this patient’s condition?

This patient sustained significant blunt trauma to the chest, presents to the Emergency Department with hypotension, tachycardia, a large chest ecchymosis, and palpable sternal crepitus.  The ultrasound image provided shows a subxiphoid view of the heart with a large pericardial effusion.  In the setting of trauma, this should be assumed to be a hemopericardium.  This patient has cardiac tamponade, which is considered a type of obstructive shock (Choice C).  Treatment includes IV hydration to increase preload, bedside pericardiocentesis, and ultimately, a surgical cardiac window performed by cardiothoracic surgery.  The other shock types (Choices A, B, D) do not describe this patient’s presentation.  Please see the chart below for further description of the different shock types and therapies.

 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #54," in International Emergency Medicine Education Project, September 10, 2021, https://iem-student.org/2021/09/10/question-of-the-day-54/, date accessed: July 2, 2022

What is your next action?

In case you didn’t encounter an elderly with chest discomfort today!

A 78-year-old male patient presented with chest discomfort and SOB. BP: 89/48 mmHg, HR: 128 bpm, RR: 26/min, T: 37, SpO2: 92% in room air. He has a history of lung cancer, hypertension and diabetes mellitus. Bed side ECG is done. What is your next action?

Feel free to give your answers at the comment box below.

608 - Figure3 - pericardial effusion - ECG

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Procedure – Pericardiocentesis

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Pericardiocentesis chapter written by David Wald and Lindsay Davis from USA is just uploaded to the Website!