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Cardiac Tamponade: Look for Pulsus Paradoxus in the Arterial Line

Monica Palma Anselmo, Lisete Rolo Nunes

Cardiac tamponade is a life-threatening condition with a myriad of etiologies. The diagnosis is challenging and when left undiagnosed and untreated this results in a significant mortality. We present a case of a sixty-nine-year-old male with a history of stage IV breast cancer that was hospitalized with a recurrent right-side pleural effusion. A thoracocentesis was performed, and the drain removed five days after. As a complication he had extensive subcutaneous emphysema. On the day of the ICU admission, he became obnubilated, with worsening of hypoxemia, hypotensive and anuric. High flow nasal cannula and norepinephrine were started. A right-side chest drain was inserted. Despite the slight improvement in oxygenation, the patient remained in shock. The arterial line showed pulsus paradoxus leading to the suspicion of cardiac tamponade. The exuberant emphysema made the acoustic window very poor but a huge pericardial effusion with heart swing and collapse of right cavities confirmed the diagnosis. A pericardiocentesis was performed with the resolution of shock. This case highlights the importance of reading and interpreting the invasive arterial line curve in the differential diagnosis of shock patients, particularly in those with poor echocardiogram acoustic window.