Concomitant intravascular and extravascular obstructive shock: a case report of cardiac angiosarcoma presenting with pericardial tamponade

Abstract

Atraumatic pericardial tamponade and intracardiac masses are both recognized etiologies of acute obstructive shock. Pericardial tamponade, is a cardiovascular emergency commonly considered by emergency physicians and, as a result, evaluation for this process has been incorporated into standardized point of care ultrasound algorithms for assessing hypotension. Obstructive shock secondary to intracardiac tumors is an atypical clinical presentation, and although it is evaluated by the same ultrasound imaging modality, it is generally not considered or evaluated for in the emergency department setting. The concomitant presentation of these two pathologic processes is an extremely rare oncologic emergency. Existing literature on the subject is found in a small number of case reports with nearly no prior descriptions in emergency medicine references. In the right clinical context this unique presentation should be considered and evaluated for in the emergency department via point of care ultrasound modality to help guide in the management of the resulting obstructive shock.

Keywords: Case report; Critical care; Emergency medicine; Resuscitation; Shock.

Fig. 1.

Electrocardiogram prior to pericardiocentesis demonstrating both low voltage and tachycardia.

Fig. 2.

Chest X-ray demonstrating "water-bottle" heart suggestive of pericardial effusion.

Fig. 3.

The 5×5-right atrial mass (black arrow) extending into the vena cava (white arrowhead). Left ventricular wall (white arrow) and pericardial lining (black arrowhead) also associated with a large pericardial effusion (asterisk).

Fig. 4.

Electrocardiogram following pericardiocentesis demonstrating low voltage but marked improvement of tachycardia.