A 72-year-old man presented to the ED with five days of dry cough and generalized abdominal bloating and three days of constipation. He said he had not experienced fever, shortness of breath, chest pain, rectal pressure, or vomiting. He had a small bowel movement on the day of his presentation but felt no better, so he decided not to wait until his upcoming appointment with his primary care physician.
Vital signs were normal except for a pulse of 115 bpm. Physical exam was normal except for tachycardia. His lungs were clear, and his abdomen was benign. His differential diagnosis included constipation, gallstones, and viral upper respiratory infection.
His CBC and BMP were normal, but his liver function tests were slightly elevated. Chest x-ray showed an enlarged cardiac silhouette and a small pleural effusion on the right. His ECG is shown below. The computer ECG read showed sinus tachycardia, nonspecific ST changes, and prolonged QT interval. Do you agree?
The computer read appeared to be correct, but there was also low voltage. These findings and the chest x-ray results were new, so a large pericardial effusion was suspected.
Abdominal ultrasound showed small ascites but no gallstones or masses. Bedside echo showed a large pericardial effusion and findings suspicious for early tamponade. A formal echo confirmed tamponade, and the patient was taken to the cath lab for emergent pericardiocentesis, where 1 L of sanguineous fluid was removed. No definite cause was found.
It was unclear if the constipation and bloating were incidental to the pericardial tamponade or just represented atypical symptoms, but they were likely the former. Certainly, cough may occur with tamponade, but the typical symptoms are dyspnea and generalized weakness. Other variable symptoms include syncope, near-syncope, palpitations, and chest pain. Tachycardia and JVD are the most common exam findings. Tachycardia and low voltage, especially when new, are the most common ECG findings. Electrical alternans is far less common, but is more specific for tamponade than low voltage or tachycardia.
See the yellow highlighted area below for additional information on tamponade.
Source: The Emergency Medicine 1-Minute Consult Pocketbook.