Pulsus paradoxus: an underused tool

Abstract

was 80/40 mmHg. The electrocardiogram showed sinusrhythm (90 bpm) with no signs of myocardial ischaemia.Consciousness returned within few seconds, and full con-sciousness was achieved after 3 min. The BP recoveredover time. A computed tomography scan was then per-formed to investigate the thoracic aorta. Slight pericardialand bilateral pleural effusions were observed with a normalaorta and no signs of pulmonary thromboembolic disease.At 11 a.m. a new crisis occurred with syncope, dysp-noea and diaphoresis with no chest pain. The pulse wasrhythmic with a tachycardia (119 bpm) and the systolic BPwas 85 mmHg. Consciousness returned fully within 2–3min. At recovery systolic BP was 130 mmHg, but an addi-tional 40 mmHg of pulsus paradoxus (PP) was found.Transthoracic echocardiography was unchanged. Transo-esophageal echocardiography did not reveal any signevocative of aortic rupture. Nevertheless, owing to thepresence of the PP, a possible diagnosis of cardiac tam-ponade was made together with the decision to alert thecardiac surgery ward, and to operate immediately.While the patient was being prepared for transfer to thecardiovascular surgery ward, haemodynamic parametersrapidly deteriorated. The jugular veins became swollen,cardiac sounds became soft with a sudden onset of shock.The patient was intubated and ventilated. Blood and bloodyclots were removed with pericardiocentesis. At 1.00 p.m. acardiac arrest occurred. Cardiopulmonary resuscitation wasbegun. At 2.10 p.m. the patient was in asystole.Autopsy demonstrated blood in the pericardium (450ml), with blood clots. An aortic dissection inside the peri-cardium was found, beginning at 0.5 cm from the aorticvalve and extending 7 cm.