Emergency Medicine

Case of the Month

History and Physical:

Pt is a 73 y/o female with pmh of HTN, COPD, CHF and MI “years ago” who presents with chest discomfort, lightheadness, mild non exertional SOB x 1 day. She was discharged from an outside hospital yesterday after pacemaker implantation.

Triage vitals:
98.5
113
20
142/93
100% RA

Initial EKG:

More history:

Awoke this AM with nausea and lightheadness. Syncopized after getting out of bed. Awoke on floor—was able to get up. Nausea and vomiting x 3 today, tolerating po liquids. Also complaining of sharp, pleuritic substernal CP. Currently has chest pain.

ROS:

Gen: generalized weakness and fatigue. No fevers at home
CV: substernal chest pain. No palpitations no orthopnea or PND
Resp: mild dyspnea. No cough
GI: N/V x 3 no diarrhea or abdominal pain

Physical Exam:

VS: 97.5 110 25 110/75 96%
Gen: Alert, NAD
CV: rrr no m/r/g
Pulm: CTA b/l
Abdomen: soft, nt, nd
Ext: no edema

What would you do next?

 

 

Initial Treatment:

ASA 162 po
IVF 1 L IV started

basic labs and cardiac enzymes drawn
CXR ordered

B Blocker ordered and nitroglycerin ordered

Telemetry admission for rule out MI planned

Before B blocker was administered, heart rate is noted to be in the 60's. 

An EKG was repeated, and is shown below:

 

Treatment continued:

Cardiology called to interrogate pacemaker: finds appropriate atrial sensing with intermittent failure to capture. Voltage increased. Heart rate remains in the 60's.

1 hour after arrival, pt became hypotensive with BP 81/40. A second IV line is placed and 2 liters IV fluid started. 

2 hours after arrival chest xray performed.  Soon afterward, pt cried out and began retching.  She was found to be diaphoretic and remained hypotensive.  Cardiology was recalled and arrived at bedside.

 

Chest xray is shown below. 

 

What is the diagnosis?

Cardiac perforation resulting in cardiac tamponade

 

Explanation of case:

The pacemaker tip can be clearly seen in the patient's pericardium on the chest xray, as demonstrated in the xray below.

 

The pacer lead had punctured the patient's right ventricle, causing her to bleed into the pericardium.  Since the pacer lead was floating in the pericardium, rather than imbedded in the ventricle, the capture was intermittent, as seen on the second EKG.  This is also why increasing the voltage of the pacer had no effect. As she continued to bleed into her pericardium, she developed cardiac tamponade, becoming hypotensive and increasingly ill.  The patient remained hypotensive despite aggressive fluid resuscitation. Cardiothoracic surgery was consulted for emergent pericardial window placement.  Cardiac perforation is a complication that is seen after recent pacemaker implantation.  It can be seen under fluoroscopy and on CXR. This diagnosis should be considered in patients with a recently implanted pacemaker who present with chest pain or with failure to capture on the EKG.  Depending on the size of the bleed, the patient may or may not have cardiac tampanade  Although these patients usually present within a few days of pacer implantation, if the bleeding is slow, they can present with tampanade a more than a week after implantation.

 

Case by Miriam Kulkarni, MD