POINT-OF-CARE ULTRASOUND EVALUATION IN CARDIAC TAMPONADE: FIRST DESCRIPTION OF A "SONOGRAPHIC EWART SIGN"

Abstract

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Diagnosing a large pericardial effusion using Point of care ultrasound (POCUS) can be done rapidly and, if needed, may expedite intervention. In 1896, Dr William Ewart described 12 physical exam signs that were indicative of large pericardial effusions needing surgical intervention due to cardiac tamponade. The tenth physical finding, “The Posterior Pericardial Patch of Tubular Breathinq and Agophony” (1) was believed to be “very commonly, if not always, present in cases of considerable effusion"(1). This physical examination finding, described 123 years ago, has been dubbed Ewart’s Sign. We present a sonographic depiction of this classical physical exam finding in a patient who presented with cardiac tamponade to intensive care unit. CASE PRESENTATION: 55-year-old male patient with a past medical history of End Stage Renal Disease, who presented with breathlessness at rest, low blood pressure and new onset atrial fibrillation with rapid ventricular response during hemodialysis. On physical exam, his blood pressure was 94/68 mmHg, heart rate of 124 bpm and respiratory rate of 24 bpm. He had a pulsus pardoxus of 15 mmHg, dullness to percussion of the left posterior chest at the tip of the scapula. Asucultation revealed bronchial breaths sounds and egophony below the left scapula (Ewart’s Sign). A bedside POCUS showed a large pericardial effusion with tamponade physiology; diastolic collapse of the right atrium (RA) and right ventricle (RV). The probe was then placed below the tip of the scapula demonstrating a large pericardial effusion, left lung atelectasis and large left sided pleural effusion (Figure 1); the “Sonographic Ewart’s Sign”. The patient underwent thoracentesis the day of ICU admission with improvement in his breathlessness and a pericardial window the next day resulting in resolution of the cardiac tamponade. DISCUSSION: In this case, we provided a visual depiction of a classical physical exam finding accurately described 123 years ago by Dr. William Ewart using percussion, palpation, and auscultation. In an illustration in the original article, Dr Ewart placed the stethoscope “immediately below or slightly to the left of the tip of the left scapula"(1) to illicit tubular breath sounds and egophony. The sign occurs secondary to compression of the left lower lobe bronchus due to the weight of the pericardial effusion resulting in atelectasis of the left lower lobe. A 123 years later, using POCUS, we were able to visualize what was accurately described. To our knowledge, this is the first description of a "Sonographic Ewart Sign” in literature. CONCLUSIONS: In addition to the presence of large pericardial effusion, RA and RV diastolic collapse, we describe a "Sonographic Ewart Sign” as another sign that physicians could elicit in the point of care evaluation of cardiac tamponade. Reference #1: Ewart, W., 1896. Practical aids in the diagnosis of pericardial effusion, in connection with the question as to surgical treatment. British medical journal, 1(1838), p.717. DISCLOSURES: No relevant relationships by Thamer Sartawi, source=Web Response No relevant relationships by Christine Warner, source=Web Response No relevant relationships by Peter White, source=Web Response