Hypovolemia-induced Cardiac Tamponade in a Patient with Hypothyroidism

Background

Pericardial effusion occurs frequently in patients with hypothyroidism and is typically mild. Although extremely uncommon, massive pericardial effusion can compromise hemodynamics and cause cardiac tamponade. Reduced plasma volume has been reported to induce cardiac tamponade in massive pericardial effusion, but to our knowledge, hypovolemia-induced cardiac tamponade has not been reported in cases of hypothyroidism with pericardial effusion.

Objectives

We describe a case of hypothyroidism with cardiac tamponade due to an uncommon cause that, to our knowledge, has never been reported.

Case Report

A 64-year-old woman with untreated hypothyroidism presented with acute abdominal pain and watery diarrhea. The patient experienced shock and cardiac arrest during the examination. Massive pericardial effusion was detected and cardiac tamponade was diagnosed. We suspected that the pericardial effusion was pre-existing due to an 11-year history of untreated hypothyroidism. On presentation, there was no hemodynamic compromise. Watery diarrhea persisted and intravenous fluid supplementation may have been inadequate. Hypovolemia developed and induced cardiac tamponade in the presence of the massive pericardial effusion. Successful resuscitation was achieved after cardiopulmonary resuscitation, aggressive intravenous fluid supplementation, and immediate pericardiocentesis.

Conclusion

Pericardiocentesis is indicated for hypothyroid patients with cardiac tamponade. We recommend the use of small, multi-hole catheters and daily measurement of drainage fluid. If the pericardial effusion does not resolve, a pericardial window with chest tube drainage should be performed.     

Cardiac tamponade in Russell viper (Daboia russelii) bite: case report with brief review

Background

Coagulopathy after snake bite is well known; however, cardiac tamponade as a manifestation of coagulopathy is rare.

Objective

To report a case of pericardial hemorrhage with cardiac tamponade after Russell viper bite.

Case Report

A 26-year-old man developed breathlessness after being bitten by a Russell viper. The clinical and laboratory follow-up of this case confirmed the clinical diagnosis of toxin-induced disseminated intravascular coagulation. Interestingly, pericardial hemorrhage with large pericardial effusion was evident clinically as well as on electrocardiogram and echocardiogram, as an initial presentation without any other bleeding manifestations. The patient developed cardiac arrest and was revived with cardiopulmonary resuscitation. Emergency pericardiocentesis was carried out. He was given fresh frozen plasma in addition to snake antivenin along with symptomatic management. On the third day of hospitalization, the patient’s clinical and laboratory profile returned to normal and he was discharged on the fifth day.

Conclusion

Pericardial hemorrhage may be due to toxin-induced myocardial damage or pericardial vessel injury coupled with coagulopathy, possibly in conjunction with vasculitis or endothelial damage. Practitioners and physicians should suspect and search for pericardial effusion in snake bite victims who develop breathlessness, and treat it vigorously in addition to antivenin therapy.     

A Pilot Study Examining the Viability of a Prehospital Assessment with UltraSound for Emergencies (PAUSE) Protocol

Background

Prehospital ultrasound has been shown to aid in the diagnosis of multiple conditions that do not generally change prehospital management. On the other hand, the diagnoses of cardiac tamponade, tension pneumothorax, or cardiac standstill may directly impact patient resuscitation in the field.

Study Objective

To determine if prehospital care providers can learn to acquire and recognize ultrasound images for several life-threatening conditions using the Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol.

Methods

This is a prospective, educational intervention pilot study at an urban fire department with integrated emergency medical services (EMS). We enrolled 20 emergency medical technicians – paramedic with no prior ultrasonography training. Subjects underwent a 2-h training session on basic ultrasonography of the lungs and heart to evaluate for pneumothorax, pericardial effusion, and cardiac activity. Subjects were tested on image interpretation as well as image acquisition skills. Two bedside ultrasound-trained emergency physicians scored images for adequacy. Image interpretation testing was performed using pre-obtained ultrasound clips containing normal and abnormal images.

Results

All subjects appropriately identified the pleural line, and 19 of 20 paramedics achieved a Cardiac Ultrasound Structural Assessment Scale score of ≥4. For the image interpretation phase, the mean PAUSE protocol video test score was 9.1 out of a possible 10 (95% confidence interval 8.6–9.6).

Conclusion

Paramedics were able to perform the PAUSE protocol and recognize the presence of pneumothorax, pericardial effusion, and cardiac standstill. The PAUSE protocol may potentially be useful in rapidly detecting specific life-threatening pathology in the prehospital environment, and warrants further study in existing EMS systems.     

Stroke complicating traumatic ventricular septal defect

Background

Traumatic ventricular septal defect (VSD) occurs in approximately 5% of blunt or penetrating cardiac injuries and can result in rare complications.

Objectives

To report the serious complication of stroke after a traumatic VSD.

Case report

A 27-year-old man with no previous medical history presented to the Emergency Department with aphasia and right hemiparesis after a stab wound to the chest. He underwent emergent evacuation of a pericardial effusion and repair of a right ventricular wall perforation. Head computed tomography revealed left middle cerebral artery infarct. Post-operatively, he was noted to have a cardiac murmur, and echocardiogram revealed a VSD. The VSD was surgically repaired without complication.

Conclusion

Stroke can complicate traumatic VSDs.     

Traumatic pericardial effusion: Impact of diagnostic and surgical approaches

Introduction

In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion.

Patients and methods

Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center.

Results

Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome.

Conclusions

Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.     

Incidence and Management of Hemopericardium: Impact of Changing Trends in Invasive Cardiology

Objective

As invasive cardiovascular care has become increasingly complex, cardiac perforation leading to hemopericardium is a progressively prevalent complication. We sought to assess the frequency, etiology, and outcomes of hemorrhagic pericardial effusions managed through a nonsurgical echo-guided percutaneous strategy.

Emergency ultrasound diagnosis of ovarian hyperstimulation syndrome: case report

Background

Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED).

Objectives

OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography.

Case Report

We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles.

Conclusions

This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography.     

Non-surgical management in hemodynamically unstable blunt traumatic pericardial effusion: A feasible option for treatment

Introduction

Little is known about the outcomes of deliberate non-surgical management for hemodynamically unstable patients with blunt traumatic pericardial effusion. We evaluated the efficacy of management with pericardiocentesis or subxiphoid pericardial window in hemodynamically unstable patients who reach the hospital alive with blunt traumatic pericardial effusion.

Utility of the Cardiac Component of FAST in Blunt Trauma

Background

Focused assessment with sonography in trauma (FAST) is widely used and endorsed by guidelines, but little evidence exists regarding the utility of the cardiac portion in blunt trauma. The traditional FAST includes the routine performance of cardiac sonography, regardless of risk for hemopericardium.

Study Objectives

Our goal was to estimate the prevalence of hemopericardium due to blunt trauma and determine the sensitivity of certain variables for the presence of blunt hemopericardium.

Methods

We performed a retrospective chart review of two institutional databases at a large urban Level I trauma center to determine the prevalence of blunt hemopericardium and cardiac rupture and incidental or insignificant effusions. We evaluated the sensitivity of major mechanism of injury, hypotension, and emergent intubation for blunt hemopericardium and cardiac rupture.

Results

Eighteen patients had hemopericardium and cardiac rupture (14 and 4, respectively) out of 29,236 blunt trauma patients in the Trauma Registry over an 8.5-year period. The prevalence was 0.06% (95% confidence interval [CI] 0.04–0.09%). The prevalence of incidental or insignificant effusions was 0.13% (95% CI 0.09–0.18%). One case of blunt hemopericardium was identified in the emergency ultrasound database out of 777 cardiac ultrasounds over a 3-year period. No patient with blunt hemopericardium or cardiac rupture presented without a major mechanism of injury, hypotension, or emergent intubation.

Conclusion

Blunt hemopericardium is rare. High-acuity variables may help guide the selective use of echocardiography in blunt trauma.     

Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients

Objective

Studies on humeral placement of the EZ-IO (Vidacare, Shavano Park, TX, USA) have shown mixed results. We performed a study to determine the first-attempt success rate at humeral placement of the EZ-IO by paramedics among prehospital adult cardiac arrest patients.

Methods

A retrospective cohort analysis of data prospectively collected over a 9-month period. Data are a subset extracted from a prehospital cardiac arrest study. The cohort consisted of adult cardiac arrest patients in whom the EZ-IO placement was attempted in the humerus by paramedics. Choice of vascular access was at the discretion of the paramedic; options included tibial or humeral EZ-IO and intravenous. Primary outcome is the percentage of successful placements (stable, flow, without extravasation) on first attempt. Secondary outcomes are overall successful placement, complications, and reason for failure. Data were collected during a post–cardiac arrest interview.

Results

Humeral intraosseous (IO) access was attempted in 61% (n = 247) of 405 cardiac arrests evaluated with mean age of 63 (±16) years, 58% male. First-attempt successful placement was 91%. Successful placement was 94%, considering the second attempts. In the unsuccessful attempts, 2% reported obesity as the cause, 1% reported stable placement without flow, and 2% reported undocumented causes for failure. There were also 2% reports of successful placement with subsequent dislodgement.

Conclusions

The results of this study suggest a high degree of paramedic proficiency in establishment of IO access in the proximal humerus of the out-of-hospital cardiac arrest. Few complications suggest that proximal humeral IO access is a reliable method for vascular access in this patient population.     

Therapeutic hypothermia induction via an esophageal route--a computer simulation

Objectives

Mild therapeutic hypothermia has been shown to improve outcomes after adult cardiac arrest but remains underused. Development of easier methods than currently exist to induce therapeutic hypothermia may help increase use of this treatment. We developed a mathematical model to evaluate the potential to induce mild therapeutic hypothermia through the esophagus.

Methods

Using a finite element mathematical modeling software package incorporating Pennes Bioheat equation, we predicted the changes in body temperature that would occur with placement of an esophageal cooling device containing recirculating chilled water at 10°C.

Results

Patient temperature under the simulated conditions decreased from 37°C to 33°C in approximately 40 minutes. Distribution of body temperature was not uniform in our model, with the skin surface and extremities showing a greater temperature decrease than in the patient's core.

Conclusions

Our computer simulations suggest that inducing mild therapeutic hypothermia via an esophageal route is feasible.     

Cardiac Rupture

Background

Cardiac rupture is an unusual cause of chest pain and sudden cardiovascular collapse. This diagnosis may be easily forgotten while managing a patient in extremis in the initial minutes of evaluation and resuscitation in the emergency department (ED).

Objectives

To report the benefit of immediate bedside cardiac ultrasonography in the diagnosis of cardiac rupture and its influence on emergent intervention in the ED.

Case Report

The initial electrocardiogram, performed within 5 min of arrival, of a 65-year old man who presented with 20 min duration of chest pain, showed a biphasic T wave in V1 and inverted T wave in V2, without ST-segment elevation myocardial infarction. Fifteen minutes later, he lost consciousness and was pulseless without a shockable rhythm on the monitor. Chest compressions were started and the patient was intubated. Echocardiography was performed at the bedside by the emergency physician. Cardiac contractility was grossly decreased in both ventricles and a large amount of pericardial fluid was seen. Two attempts at ultrasound-guided pericardiocentesis yielded only a few milliliters of blood. Interruptions in chest compressions were minimized during pericardiocentesis. Before transport of the patient to the operating room for definitive repair, asystole occurred. On the subsequent echocardiogram, heart contractions were absent and a hematoma was seen in the pericardial space. Resuscitation efforts were stopped. An autopsy was not performed per family request.

Conclusions

Typical ultrasonographic findings of cardiac rupture were present in this patient, who presented in extremis with chest pain. Early bedside echocardiography can be helpful in directing the initial care of critically ill patients.     

Diagnosis of unrecognized primary overt hypothyroidism in the ED

Objective

The aims of the study were to evaluate the incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the emergency department (ED) and to assess how previously undiagnosed hypothyroidism presents.

Methods

From July 1, 2002 to June 30, 2006, 56 adult patients were enrolled for further analysis.

Results

The incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the ED is 0.1%. The mean age of the patients was 75.8 ± 12.8 years (range, 27-98 years). Most of our patients presented in the winter. Individual symptoms and signs were not sensitive. Drugs (13 patients, 23%), nongoitrogenous autoimmune thyroiditis (12 patients, 21%), and previous surgery or irradiation related (11 patients, 20%) are frequent causes of unrecognized hypothyroidism in this iodine-replete region. Only 21% of patients were admitted with a correct initial impression. Half of myxedema coma patients were missed during the initial ED stay. Thirty-three patients (59%) had cardiomegaly on chest x-ray receiving further echocardiography examination. Pericardial effusion was found in 18 patients. Of these, 7 patients had moderate to large pericardial effusion, but none had cardiac tamponade. Only 6 patients have depressed left ventricular ejection fraction (<40%).

Conclusions

The diagnosis of hypothyroidism is often missed during the ED evaluation of patients at risk for this uncommon disease. Hypothyroidism should always be considered in patients who present with nonspecific symptoms suggestive of the disease, including weakness, cold intolerance, and alterations in mental status, and receive drugs impairing thyroid function or treatment of advanced head and neck cancer. In addition, patients with stable chronic heart failure or unexplained pericardial effusion warrant serum thyroid testing.     

A Case of Rapid Diagnosis of Boerhaave Syndrome by Thoracic Drainage

Background

Boerhaave syndrome is a rare and often fatal syndrome. Delayed diagnosis and treatment is closely associated with prolonged morbidity and increased mortality. In general, esophagography is usually chosen as the diagnostic procedure, but it has a relatively high false-negative rate. There are no reports, to our knowledge, regarding the efficacy of thoracic drainage, although it is easier to perform and more immediate than esophagography in the emergency department.

Objectives

To report the efficacy of thoracic drainage for rapid diagnosis and treatment of Boerhaave syndrome.

Case Report

An 80-year-old woman was admitted with vomiting and sudden onset of postprandial chest pain radiating to the back. Initially, myocardial infarction or aortic dissection was suspected, but was excluded by point-of-care tests and computed tomography (CT) scan, which revealed a left-sided pneumothorax, heterogeneous left pleural effusion, and pneumomediastinum at the lower level of the esophagus. Boerhaave syndrome was suspected and confirmed by thoracic drainage, which drained off bloody fluid and residual food such as broccoli. Emergency thoracotomy was performed within 4 h after onset of symptoms. The patient made an uneventful recovery.

Conclusion

Findings in this case indicate that chest pain, left-sided massive effusion on chest radiography, and left-sided massive heterogeneous effusion on CT scan are important for the diagnosis of Boerhaave syndrome. Subsequent thoracic drainage is useful for confirming Boerhaave syndrome, and such a strategy might lead to a good prognosis for patients with this rare but critical disease.     

Real-time cardiovascular magnetic resonance subxiphoid pericardial access and pericardiocentesis using off-the-shelf devices in swine

Background

Needle access or drainage of pericardial effusion, especially when small, entails risk of bystander tissue injury or operator uncertainty about proposed trajectories. Cardiovascular magnetic resonance (CMR) might allow enhanced imaging guidance.

Methods and results

We used real-time CMR to guide subxiphoid pericardial access in naïve swine using commercial 18G titanium puncture needles, which were exchanged for pericardial catheters. To test the value of CMR needle pericardiocentesis, we also created intentional pericardial effusions of a range of volumes, via a separate transvenous-transatrial catheter. We performed these procedures in 12 animals.Pericardiocentesis was performed in 2:47 ± 1:43 minutes; pericardial access was performed in 1:40 ± 4:34 minutes. The procedure was successful in all animals. Moderate and large effusions required only one needle pass. There were no complications, including pleural, hepatic or myocardial transit.

Conclusions

CMR guided pericardiocentesis is attractive because the large field of view and soft tissue imaging depict global anatomic context in arbitrary planes, and allow the operator to plan trajectories that limit inadvertent bystander tissue injury. More important, CMR provides continuous visualization of the needle and target throughout the procedure. Using even passive needle devices, CMR enabled rapid pericardial needle access and drainage. We believe this experience supports clinical testing of real-time CMR guided needle access or drainage of the pericardial space. We suspect this would be especially helpful in “difficult” pericardial access, for example, in distorted thoracic anatomy or loculated effusion.     

ST-Segment Elevation Myocardial Infarction vs. Hypothermia-Induced Electrocardiographic Changes: A Case Report and Brief Review of the Literature

Background

Diagnosed ST-segment elevation myocardial infarction (STEMI) usually prompts rapid cardiac catheterization response.

Objective

Our aim was to raise awareness that hypothermia can cause electrocardiographic (ECG) changes that mimic STEMI.

Case Report

Emergency Medical Services (EMS) was called for altered mental status and lethargy in a 47-year-old man with a medical history of paraplegia. His history included hepatitis C, hypertension, seizures, anxiety, and recent pneumonia treated with i.v. antibiotics. When brought in by EMS, the patient was responsive only to painful stimuli. His blood glucose was 89 mg/dL; blood pressure was 80/50 mm Hg, and ECG showed ST elevations diffusely. His vital signs in the emergency department were heart rate 53 beats/min, blood pressure 134/79 mm Hg, respiratory rate 14 breaths/min, pulse oximetry of 100%, and a rectal temperature of 32.7°C (91°F). A second ECG showed diffuse ST elevation, sinus bradycardia with a rate of 56 beats/min, and a first-degree atrioventricular block. J waves were noted in V3−V6, I and II. There were no reciprocal changes or ST depressions. A bedside ultrasound showed no pericardial effusion. The patient underwent cardiac catheterization, which showed no coronary artery disease and a normal ejection fraction. Later, hypercapneic respiratory failure with bilateral pneumonia developed and was intubated. His ECG the following day, once he was rewarmed, showed complete resolution of ST elevation and almost complete resolution of J waves.

Conclusion

Obtaining a complete set of vital signs is key to making a correct diagnosis. Hypothermia should be considered in the differential diagnosis of ST elevation.     

A systematic review of the effect of emergency medical service practitioners’ experience and exposure to out-of-hospital cardiac arrest on patient survival and procedural performance

Background and objective

Emergency medical service (EMS) practitioners’ experience and exposure to out-of-hospital cardiac arrest (OHCA) and advanced life support (ALS) procedures could be an important factor in procedural success and patient survival. We systematically reviewed the literature to examine these associations.

Methodology

We searched for publications using MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science. We included studies examining any type of EMS practitioner (e.g. paramedics, physicians) and OHCA patients of all ages and aetiologies. Two reviewers independently extracted data.

Results

The search identified 1658 citations, of which 11 observational studies of variable quality were included. The majority of studies did not adjust for important confounding factors and reported across different EMS personnel structures. OHCA survival was not consistently associated with various definitions of career experience in three studies, or with previous OHCA exposure in another study. Endotracheal intubation (ETI) was the only ALS procedure examined. Successful ETI placement was associated with the previous number of ETIs performed in four of five studies, but not career experience in three of four studies. Only one study examined OHCA outcome, and reported an increase in survival to hospital discharge when practitioners had high ETI exposure.

Conclusions

There is no clear evidence of an association with EMS practitioner career experience or exposure to OHCA cases and ALS procedures, with the exception of exposure to ETI and successful placement. However, most studies in this field had substantial risk of bias. Therefore, further studies are required before any definitive conclusions can be drawn.     

Factors influencing the decision to ICD implantation in survivors of OHCA and its influence on long term survival

Background

Knowledge is insufficient of the long-term benefit of an implantable cardioverter defibrillator (ICD) after out of hospital cardiac arrest (OHCA).

Aim

To describe the use and factors of importance for outcome in relation to ICD use among survivors of ventricular fibrillation (VF).

Methods

In consecutive patients discharged alive after OHCA in Gothenburg between 1988 and 2008 the long-term prognosis was followed.

Results

In all, there were 5443 OHCAs of which 1489 (27%) were hospitalized alive. Of those, 495 (33%) were discharged alive, of which 390 (79%) had shockable rhythm. The use of ICDs increased, but only 58 of 390 (15%) had an ICD. Among patients who received an ICD, the 2-year mortality was 2%, versus 25% of those who did not (p < 0.0001).In follow-up (mean 5.5 years; maximum 10 years), the use of an ICD showed a borderline association with mortality (adjusted hazard ratio 0.49; 95% confidence interval, 024–1.01; p = 0.052).Patients who had ICD were younger and had better cerebral function compared with patients without. Predictors for mortality were cerebral function at discharge, age, history of heart failure and myocardial infarction and no coronary angiography during hospitalization.

Conclusion

Among survivors of OHCA caused by VT/VF who had ICD during hospitalization only 2% died during the subsequent 2 years. The use of ICDs was low but increasing. Factors of importance for mortality were cerebral function at the time of discharge, age, history of heart failure and myocardial infarction and no coronary angiography during hospitalization.     

Double Simultaneous Defibrillators for Refractory Ventricular Fibrillation

Background

Out-of-hospital cardiac arrest is a leading cause of death in the United States. Ventricular fibrillation (VF) is the most common initial rhythm after cardiac arrest.

Objective

To describe a novel approach to the patient with intractable VF after cardiac arrest.

Case Report

A 51-year old man presented in cardiac arrest after a ST-elevation myocardial infarction. He remained in VF despite receiving typical therapy including cardiopulmonary resuscitation, amiodarone, lidocaine, epinephrine, and five attempts at defibrillation with 200 J using a biphasic defibrillator. VF was eventually terminated with 400 J by the simultaneous use of two biphasic defibrillators. The patient had a full recovery.

Conclusion

We present a case and supportive literature for a novel treatment of high-energy defibrillation in a patient with refractory VF.