Friday, August 21, 2015

2 weeks of chest pain, weakness. Presents with tachycardia.

A middle-aged male with no significant past history complained of chest pain for 2 weeks.  He stated that it was intermittent and there were no identifiable triggers. The pain was located at upper left chest without radiation and was "sharp" and aggravated by deep inspiration.  He endorses some SOB.

On exam he appeared somewhat lethargic, with a normal body habitus, and had the following vital signs:  BP 116/77 mmHg | Pulse 117 | Temp(Src) 36.4 °C (97.5 °F) | Resp 16 | SpO2 95%.

Cardiac exam was normal.  There was bilateral mild pitting edema.

An ECG was recorded:
What do you think and what do you want to do?
See below.

























There is diffuse low voltage.  The ECG is otherwise nonspecific.

General guideline for low voltage: less than 5 mm in all limb leads and less than 10 mm in all precordial leads.

This low voltage should call to mind pericardial effusion.  There is no electrical alternans, which would be specific for tampondade.

You should do an immediate bedside echocardiogram.  Some would say all chest pain patients in the ED should get a bedside echo.

A bedside echo was done.

Here is the parasternal view:


Huge effusion with collapse of right ventricle.


Here is the subxiphoid view:


More evidence of collapse of the RV.  You can also see echogenic fibrinous strands.

Here is the apical view:


More fibrinous strands.


The patient underwent emergent pericardiocentesis.  His creatinine returned at 5.42 mg/dL and BUN at 66 mg/dL.  No other etiology of effusion was found and a diagnosis of uremic pericarditis was presumed, although the BUN was not extremely high.  Dialysis was sufficient to prevent recurrence.

Further details which are unnecessary for the learning points are withheld in the interest of privacy.

Learning Point:

1. Low Voltage has many etiologies, but the most dangerous in emergency and critical care, especially when associated with tachycardia, is pericardial effusion.  Electrical alternans is not always present.
2. Consider a bedside ultrasound for all patients with chest pain, especially if it is worrisome and unexplained.
       Look what else you might find.
       And if you look at the valves with Doppler, look what else you might find.
3.  Pericarditis does not consistently manifest with ST elevation on the ECG.

Low voltage is caused by:

1.  Impedance due to fluid, fat, or air between the heart and the recording leads.
2.  Loss of viable myocardium (usually infarction)
3.  Myocardial infiltrative diseases such as amyloidosis or myxedema

Specific examples include:
Pericardial effusion
Pleural effusion
Obesity
Emphysema
Pneumothorax
Pneumomediastinum and Pneumopericardium (see this case)
Previous MI
Severe Dilated Cardiomyopathy
Amyloidosis
Hemochromatosis
Hypothyroidism

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