Case vignette
51yo M with renal cell cancer presents with SOB gradually worsening over 3 weeks. +Bilateral lower extremity swelling and productive cough; denies F/C.
BP 100/50, HR 115, RR 23, T 37.
Speaking in full sentences with mild respiratory distress. Diminished L sided breath sounds.
What do you see?
CP1 US 1: pericardial effusion, RA/RV collapse
CP1 US 2: pericardial effusion, RA/RV collapse
CP1 US 3: Large L pleural effusion w/ atelectatic lung
CXR: large L pleural effusion with midline shift
What are your next steps?
The patient becomes increasingly hypotensive, now with cool extremities and GCS 14. You suspect two forms of obstructive shock, tamponade and tension physiology. You place a L chest tube with 700mL serous return and send a sample for Light's criteria. BP improves to 110/60, HR to 105. Suspecting malignant pericardial and pleural effusions with gradual accumulation, you admit the patient to the MICU for discussion of pericardiocentesis.
Teaching points. Bedside US of heart/lungs rapidly speeds case resolution. The following POCUS findings are concerning for tamponade:
RA systolic collapse (sensitive)
RV diastolic collapse (specific)
Plethoric IVC (>2cm with <50% respiratory variation) (sensitive, except in cases of severe hypovolemia)
Systolic "bounce" (or interventricular dependence for advanced users)
"Man jumping on trampoline" or "John Travolta Sign" (wiggling of RV due to impaired diastolic filling)
MV inflow variation > 25%, TV inflow variation > 40% (best performed using apical 4C, pulse wave doppler)
Residents/staff: Dr. Michael Triller, Dr. Laura Waagmeester, Dr. Anna Nelson
RCC Tamponade
7/2018