Case vignette
A 32yo F w/h/o IVDU presents with SOB, CP, and fever, gradually worsening over last few days.
HR 115, BP 100/60, RR 22, SpO2 96%, T 39.0
You note painful, red, raised lesions on the patient's hands and feet. She has a diastolic murmur at the parasternal left 5th interspace and roncherous lung fields. Cap refill <2s diffusely. GCS 15.
What do you see?
CP7 PLA: pericardial effusion, RA collapse, hyperdynamic/underfilled LV, possible TV vegetation
CP7 Subxiphoid: dilated, non compressible IVC
CP7 M-mode: re-demonstrated non compressible IVC
CP7 PSA: re-demonstrated pericardial effusion with RV collapse
CP7 Apical 4: re-demonstrated pericardial effusion with RV collapse
What do you do next?
Most immediately, you are concerned for pericardial tamponade. You choose to hold a fluid bolus given her dilated IVC and ensure she is still adequately perfused clinically (she is). Meanwhile, using the Duke criteria, you identify 1 major criteria (evidence of endocardial involvement on US) and two minor criteria (IVDU, fever, Osler's nodes), diagnosing endocarditis. You order a full septic work up including 3 blood cultures (spaced over time) and broad spectrum antibiotics pending sensitivities (vancomycin and gentamicin). You discuss her care with cardiothoracic surgery who plans for an immediate pericardial I&D. You also discuss her care with medicine, cardiology, and ID, who will assess her soon.
After her I&D, a repeat US appears below.
CP7 Post I&D: improved ventricular motion
Teaching points. Endocarditis typically requires radiology performed TTE or TEE, but not always! POCUS can rapidly inform your differential, as well as identify time-sensitive diagnoses such as pericardial effusion with developing tamponade. Maintain clinical suspicion for endocarditis and reference the Duke criteria to provide support for your diagnosis.
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. Ramsey Selbak, Dr. Sam Ho
Bacterial Pericarditis + Tamponade