based on the echo, you'd have to convince me he's dying for me to agree this is tamponade. Like tell me you showed me the wrong TEE.
however, i would be concerned about the ascending aorta. where is this sliver of fluid coming from? could this be a leaking blunt traumatic dissection? I would probably stop looking at the TEE after the first 2 pics and then start looking at the CTA for PA injury or Aorta injury. PE is also on the DDx.
Here's a couple ascending aorta clips
Is that reversal of the D wave, or is that the V wave (negative inflection) with an absence of the subsequent D wave. I'm just looking at it based on the ECG gating. Not sure what a blunted/absent D wave signifies except maybe increased right heart diastolic pressures preventing some venous return.
Looking at these images on a phone is kinda hard. Some observations:
4 chamber does not look like acute temponade. No atrial systolic collapse, both ventricles look good. Deep tgx, same except RV looks emptyish. Obvious posterior collection with organizing clot that is around 2cm in diameter which is significant if acute. That absolutely needs to be investigated further. No systolic reversal of HVF.
What does the ascending aorta and AV look like?
Thx for posting.
OK, I think the consensus is that this presentation,
as it stands is not tamponade. And I concur given the clinical picture and the baseline echo that this is not frank tamponade (which I'm defining as pericardial pressure being high enough that diastolic filling is impaired to the point of decreasing cardiac output to below the minimum physiologic need).
However, patients frequently get intervention for pericardial effusions even when they are not in
frank tamponade. The clinical history of this patient: he was drunk and hobbling downtown and then got stabbed around the 4th or 5th left intercostal space close to the sternum about 12 hrs before he eventually arrived to us. At OSH, he gets CTA which is clean except for a large PEff with clot in it. AFAIK he remained hemodynamically stable from the incident to the time I see him although his Hgb is now 12 when presumably it was 15 before the incident. My colleague is on trauma that day, and the first time I hear about the patient is about 10 minutes before he gets brought up from the ED to the OR for an emergent (according to trauma surgery) pericardial window. I eyeball the EMR and the first thing I click to is the patient's vitals (as described in the OP). I call the trauma surgeon and tell him I can guarantee him this is not emergent tamponade and that he should consult cards for another echo +- percutaneous drainage if everyone deems that necessary. It appears the train is already on a runaway path as I discover that the surgeon and the pt are already in the OR as we're speaking on the phone. The pt is induced by my colleague with zero hemodynamic effects and these are TEE images that were performed pre-intervention.
So, we know this isn't overt tamponade, however do you guys consider "pre-tamponade" or "compensated tamponade" to be a diagnosis worth making....and if so should this thing be drained anyway?
The PW of the hepatic vein was of particular interest to me because as anaesthetic kinda guessed, the D wave is reversed.
The D wave is the doppler representation of the CVP y-descent, and we all know the saying "Lose the Y and then you die." Furthermore, changes in the hepatic vein doppler profile are worthy of attention when you've got a big pericardial effusion:
Pericardial effusion (PEff) is defined by an increase in the physiological amount of fluid within the pericardial space. It can appear following different medical conditions, mainly related to inflammation and cardiac surgery. Cardiac tamponade is a ...
www.ncbi.nlm.nih.gov
When integrating the totality of the data, we see:
1. He has never been hypotensive in our chart. His HR has remained between 80-100 with very brief spikes over 100.
2. His Hgb is 12 which is abnormal for a 24 yo. Presumably this drop is almost entirely attributable to pericardial blood since his chest entry wound is very small and hemostatic. I do not know the Hgb trend.
3. Echocardiographically there is no extremely specific sign for tamponade such as RV diastolic collapse or RA systolic collapse for > 1/3 of systole
4. However, the effusion is large and chunky (regional tamponade concerns), mitral inflow variation is pretty exaggerated and the RV filling pressures are pretty elevated
Knowing what you know now, if you want to monday morning QB this thing should we have:
A. Put pt in ICU, serial echo, trend Hgb
B. Drain now because as it stands the pericardium is already very full ( the PEff is approaching >2.6 cm in spots), the PEff may still be accumulating blood (and does hemopericardium pose a higher risk because it eventually becomes bulky clot?), plus he has some physiology on echo that may progress to tamponade if pericardial pressure gets any higher
