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• W4387248621 abstract "SESSION TITLE: Critical Care Case Report Posters 14 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Cardiopulmonary resuscitation (CPR) has a high rate of iatrogenic injury, and post-resuscitation imaging with computerized tomography (CT) and point-of-care ultrasound (POCUS) are recommended to define the etiology of arrest and identify associated injuries. We present a case of post-cardiac arrest delayed-onset pericardial tamponade with challenging pericardiocentesis due to a giant abdominal aortic aneurysm (AAA). CASE PRESENTATION: A 75-year-old man presented with witnessed out-of-hospital ventricular fibrillation, with return of spontaneous circulation after 15 minutes. In the ED, he was unresponsive with mottled extremities and a pulsatile abdominal mass. Electrocardiogram demonstrated inferior ST-elevation myocardial infarction. POCUS identified the AAA, and CT angiography confirmed a 10cm AAA without rupture, multiple rib fractures, and no pericardial effusion. Vascular surgery declined intervention, and over the next 45 minutes, progressive hypotension despite fluids, norepinephrine, vasopressin, epinephrine, and dobutamine prompted repeat POCUS, which identified a large pericardial effusion and right atrial and ventricular diastolic collapse. Cardiology declined intervention for the tamponade due to the giant AAA. With progressive shock and after shared decision making with the family, pericardiocentesis was performed via the subxiphoid approach using dynamic ultrasound guidance, yielding 60 mL of dark non-clotting blood with immediate improvement of systolic blood pressure by 40 mmHg. No pericardial drain was available, so a central venous catheter was placed into the pericardial space via Seldinger technique, and a total of 120 mL of blood was initially aspirated. Contrast echocardiogram demonstrated resolution of tamponade, correct catheter placement, and no evidence of free wall rupture. Hypotension recurred several times, and was responsive to aspiration of blood from pericardial drain. Family decided cardiac surgery was not within the patient's goals of care, and comfort was identified as the care priority. Pressors were discontinued, and the patient expired comfortably with family at his side. DISCUSSION: After cardiac arrest and CPR, CT and POCUS are recommended as important early diagnostic tests to define the etiology of the collapse and identify associated injuries. These showed no pericardial effusion, but with progressive hypotension, repeat POCUS identified delayed onset pericardial tamponade. Despite the giant AAA, subxiphoid pericardiocentesis and drain placement was successful, but definitive surgical intervention was not pursued given chronic medical conditions and patient and family preferences. CONCLUSIONS: Delayed presentation of pericardial tamponade after cardiac arrest must be considered despite negative initial imaging, and subxiphoid pericardiocentesis is possible despite the presence of a giant AAA using dynamic ultrasound guidance. REFERENCE #1: Miller AC, Rosati SF, Suffredini AF, Schrump DS. A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries. Resuscitation 2014;85(6):724-31. REFERENCE #2: Adel J, Akin M, Garcheva V, et al. Computed-tomography as first-line diagnostic procedure in patients with out-of-hospital cardiac arrest. Front Cardiovasc Med 2022;9:799446. REFERENCE #3: Blanco P, Figueroa L, Menéndez MF, Berrueta B. Pericardiocentesis: ultrasound guidance is essential. Ultrasound J 2022;14(1):9. DISCLOSURES: No relevant relationships by Matthew Cravens No relevant relationships by Richard Riker" @default.
• W4387248621 created "2023-10-03" @default.
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• W4387248621 date "2023-10-01" @default.
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• W4387248621 title "DELAYED-ONSET POST-CARDIAC ARREST PERICARDIAL TAMPONADE TREATED WITH SUBXIPHOID PERICARDIOCENTESIS WITH ULTRASOUND GUIDANCE DESPITE GIANT ABDOMINAL AORTIC ANEURYSM" @default.
• W4387248621 doi "https://doi.org/10.1016/j.chest.2023.07.1351" @default.
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