the case.
a 68 year old male presents to ED with left-sided pleuritic chest pain & shortness of breath. He is tachycardic, but normotensive (142 systolic) with room air saturations of 93%.On further questioning, he has no significant past medical history except that he smokes “too many” cigarettes.
This is his ECG…
- Rate.
- 115 bpm
- Rhythm.
- Regular [sinus]
- Axis.
- ~ -11* [normal]
- Intervals.
- PR ~ 200 msec
- QRS ~ 80 msec
- QTc ~ 430 msec
- Segments.
- Isoelectric ST’s
- Others.
- Low-voltage
- Precordial leads < 10mm
- No electrical alternans.
- Poor R-wave progression
- Wandering baseline
- Artefact – V4.
- Low-voltage
Interpretation.
Sinus tachycardia with low-voltage QRS & borderline first-degree heart block.
What are the differential diagnoses in this case ??
Check out LOW QRS VOLTAGE @ LifeInTheFastLane.com
Does this help ?
I think it does… well it did on the day !!
The concern…
Well circumscribed, rounded, soft-tissue density lesion in the right lower lobe.
With a suggestion of a new lung lesion associated with pleuritic chest pain & hypoxia, the diagnosis of PE was chased & a CTPA ordered…
Confirmation of right lung malignancy. No evidence of pulmonary embolism.
The CT however does carry another sinister finding…
httpv://www.youtube.com/watch?v=z1N-cxtJ0wU
Parasternal long axis…
httpv://www.youtube.com/watch?v=Ju35LxUPkr0
Apical four chamber…
httpv://www.youtube.com/watch?v=zZaKRvYXYXM
Subxiphoid view…
httpv://www.youtube.com/watch?v=bsyVjJCDsOM
Cardiac Tamponade.
Beck’s Triad.
- Hypotension
- Distended jugular veins
- Muffled (distant) heart sounds
Pulsus Paradoxus.
Pulsus paradoxus occurs in many pathologic conditions [eg. PE, RV infarct, asthma & tension PTx]. This is a clinical spectrum (not an absolute “on & off” phenomena).
In the presence of a pericardial effusion, it is suggested that pulsus paradoxus of >10mmHg helps distinguish those with tamponade from those who do not !!
Cardiac Tamponade by ECHO.
- RV collapse in diastole
Right ventricular collapse (arrows) on subxiphoid view.
- RA collapse in systole
Diastolic collapse of right atrium.
- Pulsus paradoxus on TV/MV inflow
Mitral valve inlet velocities (measured by pulse-wave doppler through MV in A4C view). Velocity variation > 25% suggests tamponade.
- IVC dilatation
Plethoric IVC without respiratory variation
Putting it together with ECHO…
Large pericardial effusion with features of tamponade. A, A4C with diastolic right-atrial collapse (arrow). B, M-mode image showing circumferential PE with diastolic collapse of RV free wall (arrow) during expiration. C, M-mode image showing IVC plethora without inspiratory collapse. (From Troughton RW, Asher CR, Klein AL: Pericarditis. Lancet 2004;363:717–727.)
Despite evidence of RV collapse & clinical pulsus paradoxus, our patient maintains normotensive.
He is taken to the interventional suite by our Cardiologists for pericardial drainage.
Cytology confirmed non-small cell lung cancer.
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition.
- Roy CL et al. Does this patient with a pericardial effusion have cardiac tamponade? JAMA. 2007 Apr 25;297(16):1810-8.
- Swami A & Spodick DH. Pulsus Paradoxus in Cardiac Tamponade: A Pathophysiologic Continuum. Clin. Cardiol. 2003. 26, 215–217.
- Troughton RW, Asher CR, Klein AL: Pericarditis. Lancet 2004;363:717–727.
- Goodman A, Perera P, Mailhot T, Mandavia D. The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade. J Emerg Trauma Shock 2012;5:72-5
- Pocket Atlas of Echocardiography.
- Tamponade. Echocardiography in ICU – Stanford University.
- Pericardial Tamponade – Ultrasound Podcast
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