Cardiac Arrest Due to Cardiac Tamponade

The patient with a history of lymphoma was seeking medical attention for a progressive shortness of breath and cough. He was started on oral antibiotics for presumed bronchitis. A chest XR was ordered (see image above).

The chest XR revealed cardiomegaly that was not present on a prior study. Shortly after, the patient came to the Emergency Room in cardiac arrest.

Emergent ECHO revealed a large pericardial effusion (labeled PF on the bottom image) with tamponade physiology and complete right ventricular collapse (labeled RV).

The patient required an emergent pericardiocentesis. The likely etiology – malignant pericardial effusion.

74 year old male with a history of hypertension presented one week after his total knee replacement complaining on a generalized weakness. The patient admitted to a low oral intake due to nausea. He continued taking his antihypertensive medications including ACE-inhibitor.

His initial work-up in the Emergency Department revealed potassium of 9.6mmol/L (normal<5.1mmol/L) and creatinine of 4.6mg/dl (normal<1.2mg/dl). The patient was also hypotensive with blood pressures in the 70’s systolic despite IVF boluses.

His EKG (see the image above) demonstrated severe QRS prolongation and absent P-waves consistent with hyperkalemia. The patient was admitted to ICU.

The etiology of the renal failure and hyperkalemia in this case is volume depletion and ATN (acute tubular necrosis) in addition to taking ACE-inhibitor.

The electrocardiographic manifestations of early hyperkalemia include peaked T-waves. Subsequently, PR interval lengthens and QRS duration increases. A variety of conduction blocks may occur at this point (left/right bundle and bifascicular blocks).

Later, the P wave disappears and the QRS widens further and may become a sine wave with subsequent cardiac arrest.

Surprisingly, the patient above did not require emergent dialysis. His potassium and creatinine improved with aggressive medical therapy.

Dextrocardia is a condition when the heart is on the right side of the patient’s chest and not the left. Usually, this is due to inborn conditions. Heart or lung surgery might also lead to dextrocardia.

57 year old female on Coumadin therapy for prevous DVT, presented with refractory hypotension. CT abdomen and chest "to rule out abscess" revealed large pericardial effusion - likely hemopericardium. ECHO confirmed tamponade physiology. Pericardiocentesis was performed.