Dr. Shannon’s Ultrasound Corner

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“A 32 year-old male presents to the ED via EMS. The call was for a reported stabbing, and per the EMTs the patient had good vitals in the field, but has become increasingly agitated with decreasing blood pressure. In the ED he is pale, diaphoretic, tachypneic and appears markedly uncomfortable. Vital signs are: Temp – UTO, HR- 122 bpm, BP- 88/63, O2 sat 100% on NRB. There is a 3 cm stab wound to the anterior L chest wall, close to midline, that is covered with a 3-sided transparent occlusive dressing. Breath and heart sounds are difficult to appreciate. The accompanying video clips reflect the patient’s cardiac and chest wall (bilateral) point-of-care ultrasound findings. What is your diagnosis and management?”

Ultrasound 1

Ultrasound 2

“This is a case of traumatic pericardial effusion resulting in tamponade. The large effusion is relatively atypical in that acute tamponade can occur with relatively low volumes due to the non-pliable nature of the intact pericardium. Here, the effusion may appear “relatively” large due to the compressive effect on the heart chambers, resulting in near-complete collapse of the right ventricle. As the heart cannot passively fill during diastole, blood delivery through the pulmonary vasculature to the left side of the heart is compromised, and cardiac output falls despite a compensatory rise in heart rate, also demonstrated here. Note that the effusion appears to layer-out within the pericardium, supporting the suspicion of hemorrhagic effusion in which the blood has had time to clot en route, potentially complicating ED therapeutic/temporizing pericardiocentesis. In this instance, as the OR and Trauma team were immediately available, the patient was treated with volume expansion and was taken to the operating room for definitive care including thoracotomy, pericardiotomy, and primary right ventricular laceration repair. The patient subsequently did well.”

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