CHEST Guidelines-A-73-Year-Old-Woman-With-Pulseless-Electrical-Acti

A-73-Year-Old-Woman-With-Pulseless-Electrical-Acti

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The case involves a 73-year-old woman with a history of heart failure, severe pulmonary hypertension, and chronic kidney disease, who presented with symptoms of weakness and shortness of breath. She was admitted to the ICU with low blood pressure and required inotropic support and diuresis for new right ventricular failure and atrial fibrillation. Despite initial improvement, the patient developed acute kidney injury due to over-diuresis, leading to plans for hemodialysis. On the day of the planned hemodialysis catheter placement, she suffered ventricular tachycardia followed by pulseless electrical activity (PEA) arrest. Point-of-care ultrasound (POCUS) revealed a large pericardial effusion causing cardiac tamponade, leading to the cardiac arrest. Emergency pericardiocentesis was performed, which successfully restored circulation, draining 500 mL of pericardial fluid immediately and an additional 600 mL subsequently.<br /><br />The discussion emphasizes the value of POCUS in diagnosing cardiac tamponade swiftly, which is crucial as the signs and symptoms of tamponade are not always specific. Pericardiocentesis is a lifesaving intervention in cases where pericardial effusion causes hemodynamic instability or cardiac arrest. The case also highlights that patients on factor Xa inhibitors, like the woman in this case, might benefit from reversal agents such as adexanet alfa in the occurrence of hemorrhagic pericardial effusion. After reversing the Xa inhibitor effect and the pericardiocentesis, the patient recovered and was discharged. This reinforces the recommendation for rapid assessment and intervention upon suspicion of a tamponade-related event to prevent dire outcomes.

Keywords

heart failure

pulmonary hypertension

chronic kidney disease

right ventricular failure

atrial fibrillation

cardiac tamponade

pericardiocentesis

point-of-care ultrasound

factor Xa inhibitors

hemodynamic instability