POP! GOES THE PERICARDIUM: DRAINAGE OF PERICARDIAL TAMPONADE VIA CHEST COMPRESSIONS

Abstract

SESSION TITLE: Case Report Semifinalists 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pericardial effusions are a common finding in critically-ill patients and may be caused by trauma, surgery, infection, inflammation, malignancy, or other less common medical conditions. Although the majority are asymptomatic, up to 30% of large effusions can result in hemodynamic consequences. Cardiac tamponade constitutes a medical emergency and is managed emergently by pericardial drainage either in the form of pericardiocentesis or pericardial window. Here we present a case of cardiac tamponade resulting in cardiac arrest, in which chest compressions resulted in rupture of the pericardium and spontaneous drainage. CASE PRESENTATION: A 65-year-old man with metastatic adenocarcinoma of unknown primary was admitted with multiple complaints including dyspnea, epigastric pain, weakness, and weight loss. Electrocardiogram (ECG) revealed electrical alternans. Computed tomography (CT) scan and echocardiogram confirmed the presence of a large pericardial effusion. Given the patient’s known malignancy and lack of hemodynamic instability, the effusion was deemed likely a chronic malignant effusion and was scheduled for elective pericardiocentesis. However, after admission the patient became hypotensive and was transferred to the Cardiac Intensive Care Unit for pericardiocentesis. While preparing for the procedure, the patient became pulseless and cardiopulmonary resuscitation (CPR) was initiated. After a few minutes of CPR, return of spontaneous circulation was achieved (ROSC). Point of care ultrasound was then used to guide pericardial drainage but no fluid could be visualized, therefore pericardiocentesis was not performed. A subsequent CT angiogram of the pulmonary arteries confirmed resolution of the pericardial effusion but also revealed new bilateral pleural effusions. Chest tube drainage of the right effusion was serosanguinous, and drainage of the left effusion revealed thick, dark, sanguinous fluid; both effusions were positive for adenocarcinoma. DISCUSSION: Traumatic injuries to the ribs, sternum, and trachea are common during CPR; injuries to the heart, lungs, and abdominal organs are also less commonly encountered. Fractured ribs may lacerate the pericardium, myocardium, pleura, or vasculature, and these injuries are often fatal if not surgically repaired. This case illustrates the importance of immediate pericardial drainage in tamponade, and suggests that urgent drainage should be performed in symptomatic (but hemodynamically stable) patients when the etiology or chronicity are unknown. Few case reports have described rupture of pericardial effusions from CPR, usually in the setting of acute aortic dissection or ventricular free wall rupture. CONCLUSIONS: CPR can result in the rupture of the pericardium and subsequent drainage of tamponade. We present the first reported case of a malignant effusion drained via CPR. Reference #1: Buschmann CT, Tsokos M. Frequent and rare complications of resuscitation attempts. Intensive Care Med. 2009 Mar;35(3):397-404. Reference #2: Ariyarajah V., Spodick D.H. Cardiac tamponade revisited: a postmortem look at a cautionary case. Tex. Heart Inst. J. 2007;34:347–351. Reference #3: Cornily JC, Pennec PY, Castellant P, Bezon E, Le Gal G, Gilard M, Jobic Y, Boschat J, Blanc JJ. Cardiac tamponade in medical patients: a 10-year follow-up survey. Cardiology. 2008;111(3):197-201. DISCLOSURES: No relevant relationships by Kevin Proud, source=Web Response No relevant relationships by Robert Winsett, source=Web Response