Thread by @msiuba

A new #echofirst #POCUS #medthread CASE!

55 yo woman with hx of metastatic lung CA, known malignant pleural/pericardial effusions presents as a transfer in shock with associated encephalopathy. HR 120s-130s (sinus), cool extremities, MAP 65 on 8-10 mcg/min norepi. O2 4L NC.

What are you going to do based on the above image?

The LV cavity appeared small/underfilled to you in the first image, not sure why, but you elect to bolus IV fluids while you complete your exam. You move to the A4C view and notice this:

You noticed something that looks tethered from the apex to the pericardium. This is just bizarre enough that you move to another view to confirm what you're actually seeing. Here's the PSAX:

And finally the IVC

Given the combination of findings above, what do you do?

This is an unusual case of obstructive shock/pericardial tamponade mainly affecting the L heart due to the adhesion/loculation within the pericardium. There may also have been some chronically elevated R sided pressures giving the appearance you see.

This patient underwent pericardial drainage of 100 ml with improvement in hemodynamics, prior to going to the operating room for a window. Remember that intubating a patient with tamponade can be a fatal event if not appropriately stabilized.

See this nice review for *typical* hemodynamic findings of cardiac tamponade.

derangedphysiology.com/main/required-…

And #litfl lifeinthefastlane.com/ccc/pericardia… for echo findings. /fin