Citation: Bernstein V. Cool County Cases - Aortic Dissection with Hemopericardium and Cardiac Tamponade [Internet]. Cook County Emergency Medicine Residency;Available from: https://cookcountyem.com/blog/2023/9/15/cool-county-cases-aortic-dissection-with-hemopericardium-and-cardiac-tamponade
The Case:
A 40-year-old man with no known past medical history presented for evaluation of chest pain. According to the patient’s fiancée, the patient was experiencing chest pain one day prior to presentation. He continued to have chest pain and was seen at an urgent care clinic, where he was referred to the Emergency Department for an abnormal EKG and chest radiograph. While in the waiting room, the patient had a syncopal episode and was brought back to a station. \ The patient has no significant surgical or family history. He is a lifelong nonsmoker and occasional social drinker.
On exam, the patient had initial vitals of T 36.9 °C, HR 80 bpm, BP 85/46 mmHg, RR 14 bpm, and O2 saturation 98% on room air. His exam was notable for a tall, drowsy-appearing man with pale conjunctiva, diaphoresis, symmetric and strong bilateral radial, pedal, and femoral pulses, distant heart sounds, normal lung sounds, non-tender abdomen, opening eyes to voice and able to follow commands, oriented x3. A bedside cardiac ultrasound was obtained and displayed an aortic dissection flap, a dilated aortic root, and a pericardial effusion with early diastolic collapse consistent with aortic dissection complicated by hemopericardium with tamponade physiology (Figure 1).
Cardiology and cardiothoracic surgery were emergently consulted for concern for aortic dissection with resultant hemopericardium with tamponade physiology. The patient was given 2L NS via pressure bag, which improved his mentation and blood pressure. A chest, abdomen, and pelvis CT angiogram was obtained, demonstrating a “Stanford type A aortic dissection complicated by hemopericardium and likely cardiac tamponade. The aortic root is aneurysmal, measuring up to 7.4 cm in greatest diameter. The dissection flap extends proximally from the aortic root to the proximal/mid descending thoracic aorta.” A later addendum noted a “tulip-bulb appearance of the aortic root, which is disproportionately aneurysmal compared to the ascending aorta, the constellation of findings may reflect a connective tissue disorder such as Marfan's or Ehlers-Danlos syndromes.” The patient became tachycardic to 110s and began having worsening chest pain. Subsequently, an esmolol infusion was started along with several doses of fentanyl for pain control. The patient was taken immediately to the OR by cardiothoracic surgery for dissection repair. Increased chest tube output and hypotension complicated the patient's post-operative course, requiring two take-backs to the OR. The patient was ultimately placed on VA ECMO with an IABP and transferred to an outside hospital for further management.
Clinical Questions:
1. What ultrasound findings are consistent with pericardial tamponade?
Cardiac tamponade should be suspected in a patient with bedside cardiac ultrasound demonstrating the presence of pericardial effusion with diastolic RV collapse (>90% specificity), systolic RA collapse, a plethoric IVC, and variation in mitral and tricuspid valve inflow velocity (sonographic pulsus paradoxus).
2. What is the initial management of patients with aortic dissection?
The primary focus of the initial management should be to decrease heart rate and blood pressure to avoid further injury. First-line agents include esmolol (500 μg/kg IV bolus over 1 min followed by 50 μg/kg/min IV continuous infusion) and labetalol (10-20 mg IV repeated up to 300mg total). Additional vasodilators or antihypertensives such as nicardipine, clevidipine, nitroglycerin, or nitroprusside can also be considered. Adequate pain control is also an important component of treatment to avoid tachycardia and hypertension (e.g. fentanyl IV PRN). An emergent consult to cardiothoracic surgery should be placed to determine if operative repair is necessary.
3. What is the evidence for pericardiocentesis in aortic dissection with tamponade?
There is limited but promising evidence regarding the role of pericardiocentesis in aortic dissection with tamponade. In a single-center retrospective review, Isselbacher et al. (1994) showed that of 10 patients who presented with aortic dissection with tamponade, 7 of those were normo- or hypotensive. Of those, 4 successfully received emergent pericardiocentesis, and 3 patients experienced cardiac arrest. The other 3 normo- or hypotensive patients who did not undergo successful pericardiocentesis were managed operatively and survived. However, those patients who received pericardiocentesis had between 100-300mL of blood removed. In another single-center retrospective review, Cruz et al. (2015) showed that of 21 patients who presented with type A dissection, 6 had tamponade treated with pericardiocentesis, and of those, 5 showed hemodynamic improvement. In 2015, the European Society of Cardiology recommended considering perioperative pericardiocentesis to maintain hemodynamic stability prior to definitive operative management, removing small volumes (5-10mL) as needed to maintain hemodynamic stability and avoid worsening of the dissection.
Author: Vladimir Bernstein, MD
References:
Cruz I, Stuart B, Caldeira D, Morgado G, Gomes AC, Almeida AR, Loureiro MJ, João I, Cotrim C, Pereira H. Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic surgery. Eur Heart J Acute Cardiovasc Care. 2015 Apr;4(2):124-8. doi: 10.1177/2048872614549737. Epub 2014 Sep 2. PMID: 25182464.
Isselbacher EM, Cigarroa JE, Eagle KA. Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful? Circulation. 1994 Nov;90(5):2375-8. doi: 10.1161/01.cir.90.5.2375. PMID: 7955196.
Johnson GA andPrince LA. Aortic Dissection and Related Aortic Syndromes, in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e, J.E. Tintinalli, et al., Editors. 2016, McGraw-Hill Education: New York, NY.
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Tsukube T and Okita Y. Cardiac tamponade due to aortic dissection: clinical picture and treatment with focus on pericardiocentesis. E-journal of cardiology practice. 2017 Oct;15(18).