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USMLE® Step 2 Question of the Day: Cardiac tamponade

Osmosis Team
Nov 29, 2023

We're back with a USMLE® Step 2 CK Question of the Day! Today's case involves a 66-year-old woman with metastatic breast cancer and worsening shortness of breath is found to have a large pericardial effusion and right ventricle compression. What should be the best next step in her management to address this critical condition?

A 66-year-old woman is brought to the emergency department by ambulance for shortness of breath. She reports that over the past 2-3 days she has had worsening shortness of breath with, and now without, exertion. She is currently being treated for metastatic breast cancer with chemotherapy and radiation. Past medical history is significant for hypertension, hyperlipidemia, and diabetes. Temperature is 37°C (98.6°F), blood pressure is 90/61 mmHg, pulse is 121/min, respiratory rate is 16/min, and oxygen saturation is 92% on room air. Cardiopulmonary examination demonstrates jugular venous distention. Point of care ultrasound shows a large pericardial effusion and compression of the right ventricle. Which of the following is the best next step in management?

A. Pericardiocentesis

B. Cardiac catheterization

C. Emergent dialysis

D. CT of the chest with contrast

E. Administration of aspirin

Scroll down for the correct answer!

The correct answer to today's USMLE® Step 2 CK Question is...

A. Pericardiocentesis

Before we get to the Main Explanation, let's see why the answer wasn't B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!

Incorrect answer explanations

Today's incorrect answers are...

B. Cardiac catheterization

Incorrect: This patient has evidence of pericardial tamponade and should undergo emergent pericardiocentesis. Cardiac catheterization is indicated for patients with suspicion of underlying ST-elevation myocardial infarction (STEMI).

C. Emergent dialysis

Incorrect: Emergent dialysis is often indicated for patients with cardiac tamponade secondary to uremia following pericardiocentesis. Given that this patient has evidence of hemodynamic instability, she should first undergo emergent pericardiocentesis.

D. CT of the chest with contrast

Incorrect: CT of the chest with contrast is indicated for diagnosis of a pulmonary embolism.  While this patient's malignancy history places her at increased risk for thromboembolism, her presentation is more consistent with pericardial tamponade.

E. Administration of aspirin

Incorrect: Aspirin is indicated in the management of acute coronary syndrome. This patient has evidence of pericardial tamponade and hemodynamic instability requiring emergent intervention with pericardiocentesis.

Main Explanation


cardiac tamponade

This patient with a history of metastatic breast cancer presents with shortness of breath, jugular venous distention, and ultrasonography demonstrating evidence of a large pericardial effusion with compression of the right ventricle consistent with pericardial tamponade. Given this patient's associated hemodynamic instability, the best next step in management is pericardiocentesis.

Cardiac tamponade is a life-threatening condition characterized by excessive fluid accumulation in the pericardial sac, which exerts pressure on the heart and decreases the filling of the cardiac chambers, eventually reducing cardiac output. Cardiac tamponade can occur due to effusive-constrictive pericarditis, often as a result of infection, uremia, or malignancy. Patients with cardiac tamponade are typically hemodynamically unstable and may quickly develop cardiovascular collapse and cardiac arrest. They require prompt recognition and treatment with emergent pericardiocentesis to drain the pericardial fluid and restore cardiac output. 

Acute management of patients with suspected cardiac tamponade includes an airway, breathing, and circulation assessment. Patients with evidence of hemodynamic instability should have their airway stabilized, IV access obtained, and supplemental oxygen applied as needed.  Patients should have intravenous fluids administered if they are hypotensive, and a bedside ultrasonography should be performed immediately. Additional work-up includes obtaining a twelve-lead ECG, as well as a chest x-ray. Characteristic ultrasonography findings include large pericardial effusion, as well as compression of the right atrium during systole, and RA collapse during diastole. Patients with these findings should undergo immediate percutaneous pericardiocentesis prior to further diagnostic evaluation and management.

Major takeaway

Acute management of patients with cardiac tamponade who are hemodynamically unstable includes administration of intravenous fluids as well as immediate pericardiocentesis.

References

Chiabrando JG, Bonaventura A, Vecchié A, Wohlford GF, Mauro AG, Jordan JH, Grizzard JD, Montecucco F, Berrocal DH, Brucato A, Imazio M, Abbate A. Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020 Jan 7;75(1):76-92. doi: 10.1016/j.jacc.2019.11.021. PMID: 31918837.

Little, W. C., & Freeman, G. L. (2006). Pericardial disease. Circulation, 113(12), 1622–1632. https://doi.org/10.1161/CIRCULATIONAHA.105.561514

Adler, Y., Charron, P., Imazio, M., Badano, L., Barón-Esquivias, G., Bogaert, J., Brucato, A., Gueret, P., Klingel, K., Lionis, C., Maisch, B., Mayosi, B., Pavie, A., Ristic, A. D., Sabaté Tenas, M., Seferovic, P., Swedberg, K., Tomkowski, W., & ESC Scientific Document Group (2015). 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). European heart journal, 36(42), 2921–2964. https://doi.org/10.1093/eurheartj/ehv318

Swartz MN. Clinical practice. Cellulitis. N Engl J Med 2004; 350:904.

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