B49-34 Point-of-care Ultrasound Enables Timely and Accurate Diagnosis of Cardiac Tamponade From a Rapidly Growing Uremic Pericardial Effusion: A Case Report

Abstract Point-of-care ultrasound (POCUS) has become an invaluable tool in the rapid bedside assessment of patients, allowing for the prompt identification of critical and potentially life-threatening conditions, even in the absence of clear clinical signs. We present a young patient without typical findings such as Beck’s triad (hypotension, jugular venous distension, and muffled heart sounds), however POCUS revealed an acute cardiac tamponade, leading to immediate intervention. A 21-year-old male pediatric patient with multiple relapsed B-cell acute lymphoblastic leukemia, who received Chimeric Antigen Receptor T cell therapy, was admitted for hematopoietic stem cell transplant. He developed bacteremia, mucositis, respiratory insufficiency, severe refractory thrombocytopenia, and worsening hepatic and renal injury. The critical care medicine team was consulted for consideration of hemodialysis, given worsening dyspnea and acute anuria. Chart review revealed potassium of 5.1 mEq/L, BUN/Cr of 113/ 3.0 mg/dL, an anion gap of 22 mEq/L, hemoglobin of 8.2 g/dL and platelet of 23 x 103/uL with 4 units of red blood cells transfusion and daily platelet transfusion in 7 days. Coagulation studies showed aPTT 15.7 seconds and INR 1.24. A transthoracic echo (TTE) performed five days before showed only a small pericardial effusion. On bedside evaluation, the patient was oriented and complained about worsening dyspnea with orthopnea. Physical examination revealed a tripoding young man, normotension, a heart rate of 90s, muffled heart sounds, and bilateral lower extremity edema. Bedside POCUS revealed a large pericardial effusion, with right atrial diastolic collapse, a non-collapsing right ventricle in diastole, and an inferior vena cava (IVC) 2 cm with 20% of collapsibility, findings consistent with early cardiac tamponade. Shortly after examination, he had a sudden cardiac arrest after walking to the bathroom. He was successfully resuscitated. Emergent pericardial drain was placed with approximately 950 ml of bloody fluid drained. The patient was managed in the ICU and downgraded two weeks later to the medical ward in a stable condition. This very complex case highlights the diagnostic utility of POCUS in identifying life-threatening cardiac tamponade. The large pericardial effusion was likely uremic and developed rapidly in five days with a previously negative TTE. Without POCUS, the diagnosis may have been delayed, and initiation of hemodialysis without recognition of tamponade physiology could have precipitated cardiovascular collapse. This case underscores the importance of POCUS training for intensivists and its routine use in critical care medicine, particularly when managing patients at high risk for pericardial effusion. This abstract is funded by: None