Emergent pericardiocentesis in a dextrocardiac patient with cardiac arrest–A case report

Abstract

IntroductionPericardial effusion leading to cardiac tamponade is one of the potential reversible causes of a cardiac arrest and is considered a “can't miss” Emergency Department diagnosis. Patients with dextrocardia have variable intracardiac anatomy and with comorbid underlying cardiac diseases, can develop pericardial effusion and tamponade. Pericardial effusion in patients with reduced ejection fraction, who may have Automatic Implantable Cardioverter-Defibrillator (AICD), may cause acute pericardial tamponade. Tamponade physiology may occur even with small amounts of pericardial effusion in patients with extremely low ejection fraction. Acute pericardial tamponade is a potential reversible cause of cardiac arrest and emergent pericardiocentesis is warranted. However, literature discussing technique and appropriate performance of pericardiocentesis in patients with dextrocardia is largely lacking given the rarity of both dextrocardia and pericardial effusion with cardiac tamponade physiology in the acute care setting. Case ReportThis report describes a 76-year-old male with dextrocardia and an AICD in-place who presented to the Emergency Department in cardiac arrest secondary to pericardial tamponade. During the initial resuscitation in the emergency department, the Point-Of-Care Ultrasound (POCUS) showed no cardiac shadow towards the left hemithorax. The diagnosis of dextrocardia was suspected based on findings of POCUS and later confirmed with a quick chart review which also revealed that the AICD was placed a year prior to presentation. The effusion was drained after emergent bedside pericardiocentesis with return of spontaneous circulation (ROSC). A pericardiocentesis drain was left in place and the patient was transferred to the Medical Intensive Care Unit (MICU) following ROSC for the continuity of his care. ConclusionThis case discusses the technique and technical challenges that a physician may encounter during emergent pericardiocentesis in a patient with dextrocardia.