Diagnosis Of Cardiac Tamponade Research Articles

In-hospital outcomes of cardiac tamponade in patients with pulmonary hypertension: A contemporary analysis.

Cardiac tamponade (CT) has an atypical presentation in patients with underlying pulmonary hypertension (PH). Evidence regarding the impact of PH on CT in-hospital outcomes is lacking. We used the National Inpatient Sample database to identify adult hospitalizations with a diagnosis of CT between 2016 and 2020, using relevant ICD-10 diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients with and without a PH. Multivariate logistic regression analyses and case-control matching were performed, adjusting for age, race, gender, and statistically significant co-morbidities between cohorts. A total of 110,285 inpatients with CT were included, of which 8,670 had PH. Patients with PH tended to be older (66 ± 15.7) and female (52.5%), had significantly higher rates of hypertension (74% vs 65%), CAD (36.9% vs. 29.6%), CKD (39% vs 23%), DM (32.1%, vs. 26.9%), chronic heart failure (19.0% vs 9.7%) and COPD (26% vs 18%)(P<0.001 for all). After multivariate logistic regression, PH was associated with higher all-cause mortality (aOR 1.29; 95% CI: 1.11-1.49), higher rates of cardiogenic shock (aOR: 1.19; 95% CI: 1.01-1.41), ventricular arrythmias (aOR: 1.63; 95% CI: 1.33-2.01), longer length of stay (11 days vs 15 days), and higher total hospitalization costs ($228,314 vs $327,429) in patients presenting with CT. Despite pericardiocentesis being associated with lower in-hospital mortality, patients with PH were less likely to undergo pericardiocentesis (aOR: 0.77; 95% CI: 0.69-0.86). PH was associated to increased in-hospital mortality and a higher rate of cardiovascular complications in an inpatient population with CT. Pericardiocentesis was associated with reduced mortality in patients with CT, regardless of whether they had PH. However, patients with PH underwent pericardiocentesis less frequently than those without PH.

Pericardial effusions and cardiac tamponade in hospitalized systemic sclerosis patients: analysis of the national inpatient sample

IntroductionClinically significant pericardial effusions and cardiac tamponade in systemic sclerosis (SSc) patients is uncommon and the factors that contribute to progression of pericardial involvement in SSc patients have not been well established.MethodsA review of the national inpatient sample database was performed looking SSc related hospitalizations between 2002 and 2019. Data was collected on patients with pericardial effusions and cardiac tamponade and analyzed to identify and describe patient characteristics and comorbidities.ResultsOut of a total of 523,410 SSc hospitalizations, with an overall inpatient mortality rate of 4.7% (24,764 patients), pericardial effusion was identified in 3.1% of all hospitalizations (16,141 patients) out of which 0.2% (838 patients) had a diagnosis of cardiac tamponade. Patients with pericardial effusion were significantly more likely to have pulmonary circulatory disease (p = < 0.0001), congestive heart failure (p = < 0.0001) end stage renal disease (p = < 0.0001), diabetes (p = 0.015), and hypothyroidism (p = 0.025). Patients with cardiac tamponade were significantly more likely to have a history of coronary artery bypass graft surgery (p = 0.001) or atrial fibrillation (p = < 0.0001). Hospitalized patients with cardiac tamponade had a significantly increased mortality rate of 17.7% compared to 8.8% in patients with pericardial effusions without a tamponade physiology, with an odds ratio of 2.3 (1.97–2.86), p = < 0.0001.ConclusionPericardial effusion and tamponade are associated with increased morbidity and mortality in SSc patients. Further studies are required to explore the role of patient comorbidities and characteristics in development into pericardial effusions or tamponade.

Mediastinal gray zone lymphoma in a pregnant woman presenting with cardiac tamponade

BackgroundMediastinal gray zone lymphoma is a newly recognized rare B cell neoplasm, which is challenging in diagnosis and treatment.Case presentationIn the current study, we aimed to report a 25-year-old pregnant woman at 25 weeks of gestation who presented with chronic cough and progressive shortness of breath, hypotension, tachycardia, and tachypnea. A large circumferential pericardial effusion with compressive effect on the right atrium and right ventricle and a large extracardiac mass with external pressure to mediastinal structures were seen on trans thoracic echocardiography. The emergency pericardiocentesis was performed with the diagnosis of cardiac tamponade. Also, CMR revealed a huge heterogeneous anterior mediastinal mass, and the pathology and the immunohistochemistry of the mass biopsy revealed gray zone lymphoma with positive CD3, CD20, CD30, CD45, PAX5, and negative CD15 expression. Three courses of chemotherapy with the CHOP regimen were performed with an acceptable response every three weeks before delivery. A caesarian section was performed at 37 weeks without any problem for the patient and fetus, and chemotherapy will be started three weeks after delivery.ConclusionCardiac tamponade as an emergency condition occurred in this pregnant patient by malignant pericardial effusion and mediastinal mass pressure. Accurate diagnosis and on time interventions caused a significant improvement and a successful delivery.

Cardiac tamponade during venoarterial extracorporeal membrane oxygenation: a case report

BackgroundCardiac tamponade may present with very different signs and clinical consequences in patients who are supported with venoarterial extracorporeal membrane oxygenation. Failure to recognize cardiac tamponade in this setting can cause failure to wean from venoarterial extracorporeal membrane oxygenation, and even lead to death.Case presentationWe present a 44-year-old Caucasian female in whom cardiac tamponade manifested as venoarterial extracorporeal membrane oxygenation weaning failure. After discovering the contribution of cardiac tamponade, it was possible to wean the patient from venoarterial extracorporeal membrane oxygenation support. No clear signs of cardiac tamponade had existed beforehand.ConclusionsThe diagnosis of cardiac tamponade can be very challenging in venoarterial extracorporeal membrane oxygenation supported patients due to (patho)physiological particularities related to the parallel blood flow.

Standardized Criteria for Identification of Cardiac Tamponade on Non-Electrocardiogram-gated Computed Tomography: Correlation With Echocardiographic Findings.

To identify imaging parameters that can help in the diagnosis of cardiac tamponade on non-electrocardiogram (ECG)-gated computed tomography (CT) of the chest. Retrospective analysis of 64 patients who had undergone CT and echocardiography for evaluation of cardiac tamponade. Of 64 patients, 34 were diagnosed with tamponade and underwent pericardiocentesis for further diagnosis and treatment. CT measurements obtained were: pericardial effusion (PeEff) pocket size in 6 locations (anterior, posterior, superior, inferior, right, and left lateral), pericardial thickening, diameters of the coronary sinus, upper superior vena cava, lower superior vena cava, and inferior vena cava. In addition, cardiac chamber sizes were measured. Subjective assessment of coronary sinus compression, pericardial enhancement, and pericardial thickening were also recorded. Measurement of the sum of the right lateral and left lateral PeEff thickness resulted in 91.2% sensitivity and 86.7% specificity for cardiac tamponade with a threshold of 30mm (receiver-operating characteristic area under the curve=0.94 [0.84 to 0.98], P <0.0001). Using the combination of inferior PeEff >16mm, sum of right lateral and left lateral PeEff>30mm, and presence of pericardial thickening resulted in 56% sensitivity and 100% specificity and positive predictive value for the determination of cardiac tamponade. Our study suggests that CT measurements related to PeEff size and thickness aid in the diagnosis of cardiac tamponade.

Fatal iatrogenic cardiac tamponade due to central venous catheterization.

Fatal adverse events caused by any health professional as consequence of malpractice are uncommon. In this work, the authors report a fatal cardiac tamponade associated with a peripherally inserted central catheter (PICC) by the right jugular vein that perforated the right atrium of the heart. The diagnosis of cardiac tamponade was not detected in hospital during the intrapericardial infusion of total parenteral nutrition and was only registered during the autopsy. The postmortem examination showed a milky liquid inside the pericardial cavity compatible with thetotal parenteral nutrition administered. The catheter in its migration in the cardiac chambers, mechanically perforated the inner wall of the endocardium between the trabeculae carneae, continued its course between the myocardial fibers until it was externalized. In conclusion, cardiac tamponade, although it is an extremely rare medical complication, has a high risk of fatality specially if peripheral rather than central veins were cannulated.

CARDIAC TAMPONADE WITHOUT CHARACTERISTIC ECHOCARDIOGRAPHIC FEATURES DUE TO HIGH RIGHT HEART PRESSURE FROM PULMONARY HYPERTENSION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Introduction: Cardiac tamponade occurs when pericardial effusion leads to equalization of intrapericardial pressure and diastolic intracardiac pressure, which reduces the systemic venous-to-right atrial pressure gradient, leading to depression in cardiac output. The lower this gradient, the greater the risk for cardiac tamponade. Cardiac tamponade manifests clinically as shock, jugular venous distention, and muffled heart sounds, known collectively as Beck's triad. Typical findings on echocardiogram are right atrial and ventricular collapse.[2] These findings may not be seen in patients with elevated right-sided intracardiac pressure and can lead to misdiagnosis or delay in diagnosis of cardiac tamponade.[1] We present a patient with a cardiac tamponade to highlight this point. CASE PRESENTATION: Case presentation: A 46 year old male with hypoxia and respiratory failure from COVID-19 pneumonia supported with mechanical ventilation for several weeks developed refractory shock of multifactorial etiology. The patient was known to have pulmonary hypertension with dilated right atrial and ventricular pressure in addition to paradoxical septal motion, as seen on echocardiogram of recent past. Clinical examination revealed jugular venous distention and muffled heart sounds. Electrocardiogram detected sinus tachycardia and low cardiac voltage. Echocardiogram revealed large pericardial effusion without right atrial or ventricular collapse, and therefore cardiac tamponade was not considered as the cause of shock. As shock remained refractory to multiple vasopressors and inspiratory variation of the mitral valve inflow was noted on echocardiogram, it was decided to initiate pericardial drainage. However, the patient went into cardiac arrest before it could be performed. DISCUSSION: Discussion: A clinical diagnosis of cardiac tamponade can be made in the presence of Beck's triad. However, echocardiogram is most often relied on to make the diagnosis. The most sensitive echocardiographic findings of cardiac tamponade are right atrial and ventricular collapse.[2] Though sensitive, these changes may not be present in a patient who has preexisting elevated right sided intracardiac pressure. In such cases, the diagnosis must be based on clinical evidence and can be aided by the findings of exaggerated changes in mitral/tricuspid inflow during respiration. CONCLUSIONS: Conclusion: A hallmark finding of cardiac tamponade is right atrial or ventricular collapse on echocardiogram. However, these findings may be absent in the setting of elevated right-sided intracardiac pressure. The absence of right atrial or ventricular collapse in our patient can be attributed to the elevated right-sided intracardiac pressure due to pulmonary hypertension.[3] In such cases, the diagnosis of cardiac tamponade should be made on clinical grounds and pericardial drainage should not be delayed. REFERENCE #1: 1. Adams JR, Tonelli AR, Rokadia HK, Duggal A. Cardiac tamponade in severe pulmonary hypertension. A therapeutic challenge revisited. Ann Am Thorac Soc. 2015;12(3):455-460. REFERENCE #2: 2. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684-690. REFERENCE #3: 3. Vallabhajosyula, S., Kanuri, S., Sundaragiri, P., & Alla, V. (2014). Management of cardiac tamponade in severe pulmonary hypertension. Chest, 146(4). DISCLOSURES: No relevant relationships by George Apergis, source=Web Response No relevant relationships by Dushyant Damania, source=Web Response No relevant relationships by Aaron Douen, source=Web Response No relevant relationships by Padmanabhan Krishnan, source=Web Response No relevant relationships by George Mbolu, source=Web Response No relevant relationships by Ryan Panetti, source=Web Response

Coronary sinus diameter to inferior vena cava diameter ratio in the diagnosis of cardiac tamponade: a novel approach

Abstract Background and aim Coronary sinus (CS) as an intrapericardial, low-pressure, thin-walled structure can be easily compressed in cardiac tamponade. Whereas, inferior vena cava (IVC) is an extrapericardial structure which dilates in tamponade as opposed to the response of CS. The inverse relationship between these two venous structures may augment their role in the evaluation of tamponade imaging. Therefore, we assessed the usefullness of computerized tomographic measures of CS diameter, and also CS to IVC ratio (CS/IVC) to predict tamponade in clinically stable patients with large pericardial effusion. Materials and methods 66 clinically stable patients who had large pericardial effusions, were included to the study. CS diameter was measured from the point at 1 cm proximal to the CS ostium11. IVC diameter was measured from the segment between its right atrial orifice and hepatic vein. Results Patients with tamponade had 40% smaller CS diameter (5.3±1.8 vs 8.8±2.6 mm p&amp;lt;0.001) and 35% lower CS/IVC ratio (20.7±5.5 vs 34.7±10.5% p&amp;lt;0.001).After adjusting with other parameters, only either CS diameter or CS/IVC ratio predicted tamponade respectively. (Nagelkerke r square value for CS diameter was 53.7% and 72.1% for CS/IVC ratio). 1 mm increase in CS diameter and 1% increase in CS/IVC ratio were associated with an increased odds ratio of 59% and 39% in predicting tamponade, respectively (p value &amp;lt;0.001).In ROC analysis, a cut of value of 6.85 mm for CS diameter, had 82.6% sensitivity and 83.7% specificity for predicting cardiac tamponade (Area under the curve 0.879, p&amp;lt;0.001). Additionally, a cut of value of 27% for CS / IVC ratio had 87.0% sensitivity and 86.0% specificity for predicting cardiac tamponade (Area under the curve 0.945, p&amp;lt;0.001). Conclusion The tomographic measures of both the CS diameter and the CS/IVC ratio predicted tamponade in clinically stable patients with large pericardial effusion. Compared with CS diameter, CS/IVC ratio seemed to be a more powerful predictor of tamponade Figure 1 Funding Acknowledgement Type of funding source: None

Cardiac tamponade: an educational review.

Cardiac tamponade is a pericardial syndrome characterised by an impairment of the diastolic filling of the ventricles causing reduction of cardiac output, usually producing signs and symptoms of cardiac arrest, if untreated. The main causes of cardiac tamponade include percutaneous cardiac interventions, malignacies, infectious/inflammatory causes, mechanical complications of myocardial infarction and aortic dissection. The diagnosis of cardiac tamponade is a clinical diagnosis based on a suggestive history and clinical presentation with worsening dyspnoea, distended jugular veins, muffled heart sounds and pulsus paradoxus, and should be confirmed by echocardiography. Cardiac tamponade is a life-threatening syndrome that requires urgent treatment by pericardiocentesis. Pericardiocentesis is an interventional technique to drain pericardial fluid by a percutaneous route. The standard technique for pericardiocentesis is guided by echocardiography or fluoroscopy under local anaesthesia. Pericardiocentesis should be performed by experienced operators and carries a variable risk of complications, mainly cardiac chamber puncture, arrhythmias (ventricular arrhythmias suggest puncture of the ventricle), coronary artery puncture or haemothorax, pneumothorax, pneumopericardium and hepatic injury. The prognosis of cardiac tamponade is essentially related to aetiology. Cardiac tamponade in patients with cancer and metastatic involvement of the pericardium has a bad short-term prognosis because it is a sign of advanced cancer, on the contrary, patients with cardiac tamponade and a final diagnosis of idiopathic pericarditis generally have a good long-term prognosis.

Lifesaving Emergency Sternotomy in Traumatic Cardiac Tamponade in a Teaching Hospital in Ghana: Survival of Two Rare Cases

Introduction: Patients presenting with cardiac injuries from gunshot wounds and blunt chest trauma have high mortality, without any observed survival benefit when presenting with cardiac tamponade. Cardiac tamponade is a life-threatening hemodynamically significant compression of the heart by a sudden or gradual accumulation of collections in the pericardial space that incites and overrides the body’s compensatory mechanism. Clinical Case: We present and discuss the successful management and survival of two patients with traumatic cardiac tamponade from gunshot wounds to the precordium who underwent successful lifesaving median sternotomy at a Teaching Hospital in Ghana with a new Cardiovascular and Thoracic Surgery Unit. Discussion: Usually the diagnosis of cardiac tamponade from traumatic haemopericardium is made by clinical findings which though may not always be present especially after blunt chest trauma. EFAST is a reliable tool for diagnosing and following cardiac tamponade. Median sternotomy is the standard procedure in these patients to access and repair cardiac injury either with or without cardiopulmonary bypass. Conclusion: Emergency median sternotomy in patients with cardiac tamponade from chest trauma especially after EFAST diagnosis can be lifesaving even in less resourced centres.

Cardiac tamponade as a late complication of a minor trauma due to syncope: A case report and literature review

Haemopericardium with cardiac tamponade following minor blunt trauma is a rare, life-threatening condition. The diagnosis of cardiac tamponade as well as therapeutic management may be delayed, since the link between trauma and illness is often overlooked. We report the case of an old woman who developed a relatively delayed cardiac tamponade due to an otherwise minor blunt chest trauma following syncope.

Pulsus paradoxus.

Reviewed the etiologies, pathophysiologic mechanisms, detection and clinical significance of pulsus paradoxus in various conditions. We searched PubMed, EMBASE, and the CINAHL from inception to June 2017. We used the following search terms: Pulsus paradoxus, pericardial effusion, acute asthma, ventricular interdependence and so forth. All types of study were chosen. Legendary physician Sir William Osler truly said that "Medicine is learned by the bedside and not in the classroom." Bedside history taking and physical examination should be an integral component of clinical teaching curriculum imparted to medical students. Pulsus paradoxus is a valuable physical sign seen in many clinical conditions. Pulsus paradoxus is defined by an inspiratory fall in systolic blood pressure of greater than 10 mm Hg. Two prototype examples of pulsus paradoxus are cardiac tamponade and acute asthma. Exaggerated swings of intrapleural pressure, bi-ventricular interactions and increase afterload of the left ventricle are few of the pathophysiological mechanisms involved in the causation of pulsus paradoxus. The sensitivity of pulsus paradoxus in the diagnosis of cardiac tamponade is very high. In acute asthma, it also correlates with the severity of airflow obstruction.

An useful complication of emergent pericardiocentesis procedure in cardiac tamponade: Case report

We present a case of 19 years old patient whom was admitted to emergency service with abdominal pain and dyspnea and had prodromal symptoms for about ten days. He was hypotensive, tachycardic and dyspneic. CT scan showed large amount of free peritoneal, pericardial and bilateral pleural fluid. With the diagnosis of cardiac tamponade; emergent pericardiocentesis was done with apical approach and quick hemodynamic relief was observed. It was understood that rapid haemodynamic response was a result of complication, characterized by increasing of left pleural effusion.

Changes in the venous pulse waveform in pericardial effusion revealed by Doppler echocardiography of the superior vena cava

Echocardiography is valuable for urgent assessment of the haemodynamic significance of pericardial effusions and thus assisting in the clinical diagnosis of cardiac tamponade. Classical echocardiographic findings (e.g. respiratory variation in trans-valvular velocities) are not always present and, when seen, may be attributable to other conditions (e.g. obesity or obstructive airways disease) (1). Therefore, it is important to be familiar with other abnormalities that may be observed, such as that in the superior vena cava (SVC). SVC imaging is best performed from the right supraclavicular window, with the transducer placed vertically in the fossa between the sternal and clavicular heads of the sternomastoid muscle and with the patient lying supine and the transducer marker pointing superiorly (2). Figure 1 (and Videos 1 and 2), taken in a 46-year-old male who presented with dizziness and had a large global pericardial effusion on 2D echocardiography, illustrate the changes seen in the SVC flow profile (which reflect the changes seen in the jugular venous pulse (JVP) waveform upon physical examination) before and after pericardiocentesis. SVC Doppler interrogation may be particularly valuable for determining the dominant haemodynamic condition in patients with both pericardial effusion and suspected pericardial constriction. In cardiac tamponade, compression occurs throughout the cardiac cycle and thus ventricular filling is impaired throughout diastole, resulting in minimal or no flow into the right atrium from the SVC during diastole (i.e. absence of the diastolic wave (absent Y descent in the JVP)) (3). However, in pericardial constriction, early ventricular filling is preserved and is rapid but ends abruptly as soon as maximum intrapericardial pressure is reached, resulting in both systolic and diastolic (D) waves though the D wave has a steep deceleration slope (Fig. 2), mirroring the rapid Y descent observed in the JVP (4).

Blunt cardiac injury due to trauma associated with snowboarding: a case report

BackgroundCardiac trauma is associated with a much higher mortality rate than injuries to other organ systems, even though cardiac trauma is identified in less than 10% of all trauma admissions. Here we report blunt trauma of the left atrium due to snowboarding trauma.Case presentationA 45-year-old Asian man collided with a tree while he was snowboarding and drinking. He lost consciousness temporarily. An air ambulance was requested and he was transported to an advanced critical care center. On arrival, a pericardial effusion was detected by a focused assessment with sonography for trauma. His presenting electrocardiogram revealed normal sinus rhythm and complete right bundle branch block. Laboratory findings included a white blood cell count of 13.5 × 103/μl, serum creatine kinase level of 459 IU/l, and creatine kinase–myocardial band level of 185 IU/l.Enhanced computed tomography showed a large pericardial effusion and bleeding from his left adrenal gland. There were no pelvic fractures. A diagnosis of cardiac tamponade due to blunt cardiac injury and left adrenal injury due to blunt trauma was made. Subsequently, emergency thoracic surgery and transcatheter arterial embolization of his left adrenal artery were performed simultaneously. A laceration of the left atrial appendage in the lateral wall of his left ventricle was detected intraoperatively and repaired. His postoperative course progressed favorably, although a pericardial effusion was still detected on chest computed tomography on hospital day 35. His electrocardiogram showed normal sinus rhythm and the complete right bundle branch block pattern changed to a narrow QRS wave pattern. He was discharged on hospital day 40.ConclusionsThe present case report illustrates two points: (1) severe injuries resulted from snowboarding, and (2) complete right bundle branch block was caused by blunt cardiac injury. The present report showed blunt trauma of the left atrium with complete right bundle branch block as an electrocardiogram change due to snowboarding trauma. To detect cardiac trauma in snowboarding accidents, an examination of an electrocardiogram is required in all patients who might have a bruised chest.

Emergent CT Diagnosis of Right Ventricular Rupture Caused by Central Venous Catheter Injury

: Diagnosis of cardiac tamponade has been mainly based on clinical features and echocardiography. However, CT may be an initial tool for the evaluation of cardiac tamponade because cutting edge CT is increasingly being installed in the emergency room, and presentation of cardiac tamponade can be nonspecific. Importantly, CT has better spatial resolution compared with echocardiography. Thus, identification of the etiology of cardiac tamponade is possible on CT. We report a case of cardiac tamponade demonstrating direct leakage of contrast material from the right ventricle into the pericardial space caused by central venous catheter injury diagnosed on CT.

Cause and Long-Term Outcome of Cardiac Tamponade

Cardiac tamponade is a life-threatening condition, whose current specific cause and outcome are unknown. Our purpose was to analyze it. We performed a retrospective observational study with prospective follow-up data including 136 consecutive patients admitted with diagnosis of cardiac tamponade, from 2003 to 2013. We thoroughly recorded variables as clinical features, drainage/pericardiocentesis, fluid characteristics, and long-term events (new cardiac tamponade ± death). The median age was 65 ± 17 years (55% men). In the baseline characteristics, 70% were no smokers, 12% were on anticoagulation, and 13 had suffered a previous myocardial infarction. In the preceding month, 15 patients had undergone a cardiac catheterization, 5 cardiac surgery, and 5 pacemaker insertion. Fever was observed in 16% of patients and 21% displayed other inflammatory symptoms. In 81% of patients, pericardiocentesis was needed. The fluid was hemorrhagic or a transudate in the majority, with positive cytology in 15% and bacteria in 3.7%. Main causes were malignancy (32%), infection (24%), idiopathic (16%), iatrogenic (15%), postmyocardial infarction (7%), uremic (4%), and other causes (2%). After a maximum follow-up of 10.4 years, cardiac tamponade recurred in 10% of the cases (62% in the neoplastic group) and the 48% of patients died (89% in the neoplastic cohort). In conclusion, most cardiac tamponades are due to malignancy, having this specific cause a poorer outcome, probably as a manifestation of an advanced disease. The rest of causes, after an aggressive intensive management, have a good prognosis, especially the iatrogenic.

Cardiac tamponade as the first manifestation of primary hypothyroidism

A 61-year-old woman was admitted to the Emergency Department (ED) with head injury and loss of consciousness. Despite the severe injury she was in a clinically stable condition. Physical examination showed general swelling (including the pretibial, abdomen, and face region). Moreover, dry, coarse skin and total hair loss was observed. The patient presented poor memory and concentration, but she was alert and oriented. Clinical examination revealed blood pressure (170/100 mm Hg), heart rate 60/min, and regular respiratory rate 25/min with 94% oxygen saturation. There was neither pulsus paradoxus nor engorged jugular. Lungs were bilateral, and heart sounds were muffled. On abdominal examination, hepatomegaly and a pathological mass were found. The patient was sent for head, thorax, and abdominal computed tomography (CT), which revealed no post-injury changes in the brain except for subgaleal haematoma. Abdomen CT showed hepatomegaly and large nodular mass in the pelvic cavity. Chest examination revealed the following: bilateral pleural effusion and cardiomegaly with massive pericardial effusion depth above 6 cm (Fig. 1). Cardiac consultation with bedside echocardiography showed large pericardial effusion all around the heart, with right ventricular collapse (Fig. 2). The patient was transferred to the Cardiac Surgery Department with the diagnosis of cardiac tamponade. Urgent pericardial drainage was performed and 1000 mL of yellow-coloured fluid was obtained initially in the operating theatre and a further 2200 mL on the ward. Thyroid function tests revealed a thyroid stimulating hormone level at 60 mIU/mL and free T4 at 0.00 ng, which was significant for the diagnosis of primary hypothyroidism with high thyroid stimulation. After successful management of the cardiac tamponade the patient was sent for further endocrine investigation. It is well known that that patients with hypothyroidism can develop a protein-rich pericardial and/or pleural effusion. However, cardiac tamponade as the initial presenting feature is extremely rare. The presented case shows that a patient with hypothyroidism may not present the classic symptoms of cardiac tamponade. Chen et al. [Am J Emerg Med, 2010; 28: 866–870] and shows that the incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the ED is 0.1%. Nevertheless, our case highlights the importance of well performed anamnesis and physical examination while evaluating patients and reminds us to include hypothyroidism as the differential diagnosis in uncommon cases.

Tuberculous Pericarditis: An Unusual Cause of Cardiac Tamponade

A 29-year-old man was admitted to our department with a diagnosis of cardiac tamponade. The clinical symptoms were asthenia, fever, dyspnea, and tachycardia. A computed tomographic scan showed multiple pericardial abscesses (arrows) (Fig 1), one of which compressed the left ventricle (arrow) (Fig 2). Emergency echocardiography showed a large amount of pericardial effusion compressing the heart. Pericardiocentesis was performed immediately through a left anterior thoracotomy, and almost 0.5 L of purulent fluid under pressure was aspirated from the patient.

Late cardiac tamponade in adults secondary to tip position in the right atrium: an urban legend? A systematic review of the literature.

CENTRAL VENOUS CATHETER (CVC) placement is a very common procedure, considering that the Food and Drug Administration (FDA) has estimated that 5 to 6 million CVCs are placed annually in the United States. The FDA also receives reports that are useful in the identification of emerging problems associated with device use. More than a decade ago, one of these emerging problems was cardiac tamponade, a very rare but potentially fatal complication associated with CVC placement. Diagnosis of cardiac tamponade (CT) often is delayed, even when signs and symptoms are typical.