Serial point-of-care ultrasound successfully identified cardiac tamponade in a 56-year-old woman with ESRD and undifferentiated shock, leading to a pericardial window draining 2050 cc of fluid.
Case Report (n=1)
Serial point-of-care ultrasound is a critical tool for early recognition of cardiac tamponade in complex patients with undifferentiated shock.
Abstract Background Cardiac tamponade is a life-threatening condition caused by accumulation of fluid in the pericardial space, leading to impaired cardiac filling and hemodynamic instability. In patients with end-stage renal disease (ESRD), the risk of pericardial effusion is elevated due to uremia and fluid overload. Early recognition is critical, yet diagnosis can be challenging in patients with multiple comorbidities. Point-of-care ultrasound (POCUS) has emerged as a rapid, bedside tool for evaluating undifferentiated shock and identifying pericardial effusions. Case Presentation A 56-year-old Hispanic woman with ESRD on thrice-weekly hemodialysis, morbid obesity (BMI 41.4), hypertension, chronic diastolic heart failure, anemia of chronic disease, and liver cirrhosis with ascites presented with acute hypoxic respiratory failure, hypotension, and severe volume overload. Initial bedside POCUS in the emergency department revealed a mild pericardial effusion without evidence of tamponade physiology, and the patient was managed conservatively with hemodialysis. Despite initial improvement, on hospital day 10, she developed worsening hypotension, tachypnea, and hypoxia, prompting transfer to the ICU for undifferentiated shock. Repeat bedside POCUS demonstrated a significant increase in pericardial effusion size with new tamponade physiology. Emergent echocardiography confirmed these findings, and she subsequently underwent a pericardial window with drainage of 2050 cc of serosanguineous fluid.Postoperatively, she was managed in the ICU with ongoing hemodialysis. Her course was complicated by atrial flutter with rapid ventricular response, initially treated with amiodarone and later with transesophageal echocardiogram-guided cardioversion. The patient’s hemodynamic status stabilized, and she was successfully extubated on hospital day 13. She was discharged home on hospital day 22 with plans for outpatient follow-up and continued hemodialysis. Discussion This case highlights an atypical presentation of cardiac tamponade in a patient with ESRD and multiple comorbidities. The water bottle-shaped cardiac silhouette on chest X-ray was an early clue to pericardial effusion, while serial POCUS exams provided critical diagnostic information as the patient’s clinical status evolved. Management was further complicated by volume overload, heart failure, and liver disease, necessitating a coordinated, multidisciplinary approach involving nephrology, cardiology, critical care, and surgery. Conclusion Cardiac tamponade is a time-sensitive, potentially fatal condition that demands early recognition and intervention. In patients with ESRD, clinicians should maintain a high index of suspicion for pericardial effusion when radiographic or hemodynamic abnormalities arise. Early and serial utilization of POCUS, coupled with multidisciplinary management, can be lifesaving in complex cases of undifferentiated shock. This abstract is funded by: None
Varias et al. (Fri,) conducted a case report in Cardiac tamponade (n=1). Point-of-care ultrasound (POCUS) was evaluated. Serial point-of-care ultrasound successfully identified cardiac tamponade in a 56-year-old woman with ESRD and undifferentiated shock, leading to a pericardial window draining 2050 cc of fluid.
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