Matters of the Heart: Pericardial Tamponade

A 70-year-old woman with no previousmedical problems had had progressivedyspnea and generalized weaknessfor the past several days. She washypotensive (73/31 mm Hg), tachycardic(120 beats per minute), andtachypneic (28 breaths per minute);oxygen saturation (room air) via pulseoximetry was 84%.The patient was alert and welloriented. Her skin was cool, cyanotic,and mottled--especially on the armsand legs. Her neck veins were massivelydistended, and she had pulsusparadoxus. Cardiac sounds were decreased,and there was decreased airentry localized to the left side of thechest. An enlarged lymph node wasfound over the left supraclavicularregion.An ECG revealed sinus tachycardiawith low voltage. The chest filmseen here shows a bottle-shaped heart,and the echocardiogram demonstratesa large effusion (arrowheads) encompassingthe heart.Pericardiocentesis successfully alleviatedthe patient's symptoms andproduced 1100 mL of grossly hemorrhagic,free-flowing fluid. Cytologicexamination of the fluid revealed metastaticadenocarcinoma. The primarysite of the malignancy was determined to be a mass between the uterus andthe anterior wall of the rectum. Before the scheduled exploratory laparotomy,however, the patient left the hospital against medical advice and was lost tofollow-up.