A Clinical Rescue Pericardiocentesis with Point-of-Care Ultrasound of a Malignant Pericardial Effusion in Emergency Department

Abstract

Pericardial effusion leading to cardiac tamponade can result from a wide range of underlying causes and may develop either acutely or sub acutely. Because of this variability in presentation, timely recognition and prompt intervention are essential, especially in the emergency department where delays can significantly impact patient outcomes. We describe the case of a 54-year-old woman with advanced lung cancer who presented with progressive respiratory distress. Although her initial vital signs, including blood pressure, appeared relatively stable, further evaluation revealed subtle but important features of early cardiac tamponade. An initial misinterpretation of her electrocardiogram (ECG), along with her seemingly preserved hemodynamics, contributed to a delay in initiating definitive management. Point-of-care ultrasound (POCUS) ultimately played a pivotal role in clarifying her condition. Key sonographic findings—including right-sided chamber collapse, a plethoric and non-collapsible inferior vena cava (IVC), and the characteristic “dancing heart” sign—raised immediate concern for evolving tamponade physiology. Guided by these ultrasound findings, the emergency team proceeded with real-time, ultrasound-guided pericardiocentesis, which resulted in rapid and significant improvement in the patient’s clinical status. This case underscores the critical value of POCUS in identifying cardiac tamponade, particularly in patients who do not exhibit the classic triad or expected hemodynamic instability. It highlights the importance of maintaining a high index of suspicion and using bedside ultrasound to support clinical decision-making. Early recognition through POCUS can expedite lifesaving interventions and prevent deterioration in patients with subtle or atypical presentations of cardiac tamponade.