65 yo male represented after Ix in CPEU the day before for central dull chest pain.
Noted in ED to have diffuse ST elevation. But given normal serial troponin, d/c by cardiology with OPD MIBI booked.
Pt presented last night with further chest pain and SOB.
HR 100 BP 120/60 sats 100 RR 15
Diffuse concave ST elevation, ST depression in aVR. No PR depression/ elevation. But Deidre who saw the patient did note Spodick's sign (downsloping TP segment, particularly in lead II which is specific for pericarditis: more so than PR depression) .
But more importantly Deidre had a look with the US
parasternal long axis view. Moderate pericardial effusion with a hyper dynamic LV and collapsing RV.
RV collapse is seen during diastole when the RV pressure is at its lowest
Mitral doppler velocities showing respiratory variation >25%
So this patient has almost all the signs tamponade on echo. However, most likely he was compensating due to good LV contractility and tachycardia. Deidre did notice that with IV volume expansion, his RV collapse decreased.
In this patient I think the above echo findings are enough to get cardiology review and a formal echo overnight with a view to tapping the effusion. Because the patient is at high risk of decompensation.
Features of tamponade on echo
RV diastolic collapse (when AV valves are open)
RA systolic collapse (when AV valves are closed)
Dilated, non collapsing IVC
Respiratory variation >25% in mitral, aortic or tricuspid flow
Good educational link