(1408) Code Airway? Did You Mean Code Tamponade?

Introduction: Pericardial tamponade is a life threatening emergency and is fatal without appropriate and timely treatment. However, it can be challenging to make the diagnosis. History, exam and point of care ultrasound (POCUS) should be used to recognize early and manage critically ill patients accordingly. Here we present an unexpected diagnosis discovered when our team was called to intubate an acutely decompensating patient that changed management.

Description: A 74 year-old female with metastatic cancer was admitted to the MICU for metabolic acidosis and altered mental status. The patient was placed on HFNC and was found to have a worsening right-sided malignant pleural effusion based on chest x-ray and bedside ultrasound. An arterial blood gas at the time showed 7.19/27/130/10 with a lactic acid of 13.3. The decision was made by the primary team to call a code airway. When our airway team arrived at the bedside, the patient was tachycardic and hypotensive with a narrow pulse pressure. Our airway team decided to place an arterial line for improved hemodynamic monitoring peri-intubation. Pulsus paradoxus on the arterial line tracing coupled with the patient’s history & vital signs prompted our team to perform a bedside echocardiogram, which showed complete collapse of right atrium & right ventricle in the setting of a large pericardial effusion. Given the high probability of pericardial tamponade, the decision was made to defer intubation, knowing that it could worsen the patient’s hemodynamics. Instead, the interventional cardiology team was called to the bedside and agreed with the plan for pericardiocentesis in the catheterization lab. An urgent pericardiocentesis was completed with 250cc of bloody fluid removed and a drainage catheter left in place. The patient's respiratory status and hemodynamics continued to improve throughout the day and the patient did not require intubation.

Discussion: The diagnosis of pericardial tamponade by our airway team in a critically ill patient with sudden worsening hemodynamics and respiratory status prevented a likely catastrophic outcome had the patient undergone rapid sequence intubation and placed on ventilator with positive pressure ventilation. Our airway team routinely uses POCUS to assess any hemodynamically unstable patient prior to intubation.