110. Don’t let the obvious distract from the occult: a case of cardiac tamponade masquerading as refractory asthma

Abstract

Introduction: “Not all that wheezes is asthma” is a famous adage in medical literature, that pretty much underscores a valuable tip in the approach of dyspneic patients. Congestive heart failure is a well-known non-pulmonary cause of wheezy chests, but cardiac tamponade is not that much known as a cause. Here, we present a case of cardiac tamponade that laid behind a wheezy chest in an asthmatic patient; mimicking an asthma exacerbation. Case Report: A 69-year-old female presented to the emergency department (ED) in moderate respiratory distress during the early hours of a morning. Her shortness of breath started 2 days back and had been progressively worsening. It was associated with productive cough and nausea. Her past medical history was significant for bronchial asthma and metastatic ovarian cancer. She tried Salbutamol and Atrovent at home, but felt no improvement. Her initial set of vitals were as follows: Temperature 37.3 C, pulse 115/min, blood pressure 113/82 mmHg, respiratory rate 32/min, O2 saturation 95% on room air. She was alert, oriented, but anxious. On lungs auscultation, she was found to have bilateral wheezes, so she was assumed to be suffering from an asthma exacerbation and was managed accordingly. A diagnostic work-up was started simultaneously. The patient’s symptoms failed to respond, so the intensive care unit (ICU) team were consulted to review the case and aid in its management. Following their assessment, they came to the impression that her lungs were congested, so they started her on Bi-level Positive Airway Pressure (BiPAP) ventilation and administered a small dose of furosemide. Approximately one hour later, the patient’s condition deteriorated as she became more tachycardic and tachypneic. A junior resident with outside-the-box thinking reviewed the case and decided to do a bedside ultrasound assessment of the heart. Surprisingly, he found large pericardial effusion with diastolic right ventricular collapse. The BiPAP was stopped, a liter of normal saline plus 500 mL of Albumin 5% were given, and a pericardiocentesis was performed. About half a liter of bloody fluid was removed during the procedure, and the patient’s condition improved dramatically after it. Discussion: Cardiac tamponade is a life-threatening dilemma that can develop in the context of traumatic events or non-traumatic medical conditions. Sometimes, it can be difficult to diagnose due to its non-specific symptoms and signs. Beck’s triad, which is considered the classic presentation of cardiac tamponade, is very uncommon in clinical practice and may not be seen until late stages. In contrast to congestive heart failure (CHF), the association of cardiac tamponade with bronchospasm has been infrequently reported in medical literature. This type of presentation is particularly challenging if the patient’s past medical history is significant for asthma or CHF. Nevertheless, the use of bedside point-of-care ultrasound can significantly improve the chances of recognizing this condition in a timely fashion. Therefore, it is very important for emergency medicine physicians to have the skills of using this tool, and to use it whenever it is needed. Conclusion: Thinking outside-the-box and utilizing the point-of-care ultrasound saved this patient’s life. It is of no doubt that these two can save many other lives too.