A middle aged F with a history of non ischemic cardiomyopathy, left ventricular thrombus (on anticoagulation), status post implantable cardioverter-defibrillator (ICD) placement presents with chest pain for 5 hours. It’s constant, non-radiating, associated with dyspnea on exertion, emesis, and diaphoresis. Her electrocardiogram has a left bundle branch block, but no Sgarbossa criteria. No leg swelling, cough or fever. Lungs are clear.
Patient's BP is 70s/40s. HR in the 60s. 02 100% on RA. Patient looks pale but lying comfortably supine on stretcher bed speaking in full sentences not in acute respiratory distress.
POCUS cardiac: The focused echo shows a circumferential pericardial effusion that appears to impede filling of the right ventricle during diastole, the most specific echocardiographic sign of tamponade physiology (here best seen in the subxiphoid window). Also concerning is the plethoric inferior vena cava (IVC), which while could be due to the known cardiomyopathy, is also the most sensitive finding in tamponade physiology.
The patient had 550cc of serosanguineous fluid drained via pericardiocentesis, with the drain left open resulting in a total output of 1L the next morning. Her symptoms resolved.
POCUS Pearl: A pleural effusion can be mistaken for a pericardial effusion. To avoid this common false positive, look for the descending aorta in the parasternal long axis view. A pericardial effusion lies anterior to the descending aorta, and a pleural effusion lies posterior or adjacent to the descending aorta.