This summer a patient was admitted to our mid-tier hospital semi-unconcious with severe hypotension and tachycardia. He had a massive history of heart disease and had been complaining of recurring chest pains for three days before suddenly collapsing at home.
In the ED he was gradually becoming more and more hypotensive. On his ECG he had massive ST-elevations in all frontal ECG leads. The emergency physician suggested starting thrombolysis on a vital indication because of the ST-elevations and the cardiac history.
Still, something didn´t feel quite right. The whole presentation was a bit too progressive PEAish. Something somewhere was building up. Besides he had is first episode of chest pain three days ago, which is about the time it takes for post-MI wall ruptures and perforations to develop. A quick echocardiographic assessment wouldn´t hurt.
I got a good subcostal view and this is what stared back at us.
I am a useless echocardiographer, but this was no artefact. A massive pericardial effusion.
This is a subcostal view. You can see the large echo free space surrounding and compressing at least the right ventricle. The swirling sea-weed is most likely strands of a forming blood clot. We estimated the effusion width to at least 3 cm. Any pericardial effusion with a with a width >0,5 cm is acutely significant.
A few minutes after me courageously filming this with my iPhone, our patient´s vitals took a sharp dive to the south and he PEA arrested. Cardiac tamponade and PEA arrest.
At that stage we were still waiting for the cardiologist to pick up the phone and our radiologist to respond from home. Not good enough. We needed to fix this now. Compressions were ongoing, but CPR is not likely to help this patient at all. We had to perform an immediate pericardiocentesis.
We immediately grabbed a single lumen central line kit, ripped it open and got out the cannula.
If one looks at the ultrasound we need to drain a lumen that is almost 3 cm wide at a depth of just 5 cm from the skin.
Using the same subcostal view and in-plane cannulation it was incredibly easy to guide the cannula into the effusion. (Unfortunately there is no footage of the cannulation. Not that I was scared or anything, there just isn´t any.)
Then with a 20ml syringe we decompressed the effusion. After draining only 30-40ml of fresh blood our patients blood pressure normalised.
Vitals remained normal for 45 minutes or so before taking another dramatic drop. The effusion was building up volume, causing another tamponade.
By then I had inserted a central line catheter within the pericardium and knew what to do. After draining another 30-40ml blood pressure normalised.
I had to decompress the tamponade another two times before the retrieval team finally arrived to start what must have been a nightmarish 2h flight transfer to our nearest top tier hospital with thoracic surgical cover.