Quick Decisions

I always conduct a complete echo exam including all standard views. After all, even small details may provide important clues. However, there are exceptions - especially when the time factor is involved. The following case will show you how important it is to immediately recognize what's happening.

Code blue

Just the other day the code blue alarm went off. A patient in the cath lab was having a serious problem. We grabbed our mobile echo scanner and rushed to the site. A 78-year-old obese woman with a history of anterior myocardial infarction, apical aneurysm, and incessant therapy-refractory ventricular tachycardia was undergoing ablation of her ventricular arrhythmias.

Echocardiogram before ablation. There is a large apical aneurysm and the patient's left ventricular function is poor.

She was in poor condition when the procedure was initiated. However, we had no option than to try controlling her arrhythmia with ablation.

In shock

The patient's blood pressure dropped suddenly and she was in a state of shock shortly after transseptal puncture had been performed.
There was no time to fiddle with standard views and, since she was lying flat on her back, the best access was the subcostal window.
Here is the first view we obtained just a few seconds after I arrived.

Subcostal view. Epicardial fat or blood?

Can you see the “mass” right in front of the right ventricle? The first thing that comes to your mind is blood. Remember - she had a transseptal puncture. Perforation of the left atrium is one of the complications of this procedure. But could it also be epicardial fat?

Think quick

A quick rotation of the transducer provides the answer:

Large hematoma with moving blood; one can even see an area with free blood.

This can NEVER be epicardial fat. First, the right ventricle is also compressed. Second, it is just too much. Third, it is also around the right atrium - something that would not occur if it were epicardial fat. Just for comparison: here is the subcostal view before the procedure.

Subcostal view before the procedure showing true epicardial fat. A rather prominent lining of tissue.

Obviously, this view was not available during the echo in the cath lab. The diagnosis is now evident and calls for rapid action. We called our cardiovascular surgeons to drain the hematoma. While we were waiting, we performed pericardial puncture to relieve the tamponade. Our patient's blood pressure was dropping further.


In such a setting and in a patient who is obese, it is quite difficult to puncture the pericardial effusion. Can echo help? Yes. It can give you a clue as to where you should insert the needle, and it also permits you to check whether the drainage catheter is where you want it to be. You simply inject some agitated saline into the catheter and observe where it appears on the echo study. This was done while the following image was recorded.

Blood was drawn out of the catheter. Are we really in the pericardial sac?

Take a close look at the right ventricle. Do you see bubbles there? Not a good sign. Our catheter is placed right there. It is not in the pericardial sac.
Before trying anything else we rushed the patient to the OR. Everything was ready there. The hematoma was resolved. In fact, the bleeding actually stopped. The only site of perforation was in the right ventricle, where the catheter stuck.
How is she doing now? Not too bad. She is recovering and there is no further bleeding. The only problem is that she still has these episodes of ventricular tachycardia. Would you go for a second attempt at ablation? Definitely not right now.

Think differently

Emergency echos are a completely different “ball game” We have to focus on what we need to know first. Since the pathologies we encounter are all rather infrequent, we have to rely more on interpretation, common sense, and the patient's clinical background. All of these factors helped to arrive at a quick decision in our patient. It is always helpful to know the basics of echo. You certainly learn them in our Echo MasterClass.
For those of you who are curious to see more emergency echo cases, here are a few examples:
1st emergency case
2nd emergency case
3rd emergency case
P.S.: If you know any colleagues or friends who might benefit from the information presented in this post, please forward it to them, they will appreciate it.