Beck’s Tetrad? Adding POCUS To The Clinical Exam For Pericardial Tamponade Improves Diagnostic Accuracy In Obstructive Shock

Beck’s Tetrad? Adding POCUS To The Clinical Exam For Pericardial Tamponade Improves Diagnostic Accuracy In Obstructive Shock Cody Wiench, MD Providence Portland Medical Center – Portland, OR Additional Authors: Benjamin Pedroja, MD Introduction: Obstructive shock due to tamponade is an important, but rare, cause for sudden cardiovascular collapse. Accurate treatment requires prompt (and correct) diagnosis. Bedside echocardiogram can provide rapid and accurate diagnosis, however the physical exam can provide important clues to consider tamponade. In patients with conditions that predispose them to pericardial disease, such as SLE, one must have a high index of suspicion for tamponade when patients suddenly de-compensate. Case Presentation: A 27-year old woman with a history of SLE on chronic immunosuppression, pulmonary hypertension and chronic pain presents to the Emergency Department with subjective fevers to 40C, diaphoresis and sudden onset back pain. Vitals in the ED were impressive for heart rate of 106, blood pressure of 92/67, respiration rate of 10. Labs and imaging were unremarkable. Pt admitted to hospital for potential sepsis of unclear cause in an immunosuppressed patient and was started on vancomycin and piperacillin-tazobactam. On day 5 of hospitalization, a rapid response was called due to sudden onset of heart rate to 150, respiration rate to 24, blood pressures of 80s/50s and severe chest pain. Physical exam at that time was notable for muffled heart sounds and pulsus paradoxus. Bedside ultrasound demonstrated a large pericardial effusion resulting in cardiac tamponade. Emergent pericardial fluid drainage was preformed, draining 70 cc of fibrinous, bloody fluid. After procedure, the patient had rapid normalization of hemodynamics. Pericardial fluid analysis was performed, but nonspecific. It is thought that the effusion was secondary to SLE, and the patient was discharged to home in stable condition. Discussion: Cardiac involvement in SLE is thought to occur in more than 50% of SLE patients, however tamponade is much rarer with an estimated incidence of \u3c1% in a review series. Tamponade portends a poor prognosis in SLE patients. During acute cardiovascular collapse in SLE, one much have a rapid approach to evaluating for tamponade. Pulsus paradoxus is one of those maneuvers; in one prospective study, it was found in 2/3 of patients with tamponade. Unfortunately, patients presenting with the classical “Beck’s Triad” (hypotension, distended neck veins and distant heart sounds) is uncommon; in once study of ultrasound-confirmed tamponade, Beck’s Triad was present in 0% of patients. Fortunately, there are key findings on POCUS exam that, in conjunction with the physical exam, can lead to rapid and accurate diagnosis of tamponade, for instance the absence of a dilated IVC can exclude tamponade with 97% sensitivity.https://digitalcommons.psjhealth.org/ppmc_internal/1006/thumbnail.jp

Degradation of Internalized αvβ5 Integrin Is Controlled by uPAR Bound uPA: Effect on β1 Integrin Activity and α-SMA Stress Fiber Assembly

Myofibroblasts (Mfs) that persist in a healing wound promote extracellular matrix (ECM) accumulation and excessive tissue contraction. Increased levels of integrin αvβ5 promote the Mf phenotype and other fibrotic markers. Previously we reported that maintaining uPA (urokinase plasminogen activator) bound to its cell-surface receptor, uPAR prevented TGFβ-induced Mf differentiation. We now demonstrate that uPA/uPAR controls integrin β5 protein levels and in turn, the Mf phenotype. When cell-surface uPA was increased, integrin β5 levels were reduced (61%). In contrast, when uPA/uPAR was silenced, integrin β5 total and cell-surface levels were increased (2–4 fold). Integrin β5 accumulation resulted from a significant decrease in β5 ubiquitination leading to a decrease in the degradation rate of internalized β5. uPA-silencing also induced α-SMA stress fiber organization in cells that were seeded on collagen, increased cell area (1.7 fold), and increased integrin β1 binding to the collagen matrix, with reduced activation of β1. Elevated cell-surface integrin β5 was necessary for these changes after uPA-silencing since blocking αvβ5 function reversed these effects. Our data support a novel mechanism by which downregulation of uPA/uPAR results in increased integrin αvβ5 cell-surface protein levels that regulate the activity of β1 integrins, promoting characteristics of the persistent Mf

Brief training in ultrasound equips novice clinicians to accurately and reliably measure jugular venous pressure in obese patients.

INTRODUCTION/PURPOSE: Measurement of jugular venous pressure (JVP) by novice clinicians can be unreliable, particularly when evaluating obese patients. Measurement of JVP using ultrasound (uJVP) is simple to perform and provides accurate measurements. This study evaluated whether students and residents inexperienced with ultrasound could rapidly be taught to measure JVP using ultrasound in obese patients with the same accuracy as cardiologists measuring JVP via physical examination. Additionally, this study also evaluated the correlation between qualitative and quantitative JVP assessment. METHODS: This prospective, blinded study compared uJVP measurements performed by novice clinicians after brief training to JVP measurements performed by cardiologists (cJVP) on physical examination. Association between uJVP and cJVP was assessed using linear correlation, agreement and bias were assessed using the Bland-Altman analysis and inter-rater reliability of uJVP was assessed using intraclass correlation coefficient (ICC). The association between qualitative and quantitative JVP assessment was assessed using linear correlation. RESULTS: Novice clinicians (n = 16) obtained 34 measurements from 26 patients (mean BMI 35.5) and reported moderate-to-high confidence in all measurements. uJVP correlated well with cJVP (r = 0.73) with an average error of 0.06 cm. The estimated uJVP ICC was 0.83 (95% CI = 0.44, 0.96). Qualitative uJVP had only a moderate correlation (r = 0.63) to quantitative uJVP. DISCUSSION: Novice clinicians often have difficulty assessing JVP on physical examination, particularly in obese patients. Our findings show a high degree of correlation between JVP measurements performed by novice clinicians using ultrasound compared with JVP measurements made by experienced cardiologists on physical examination. Furthermore, novice clinicians were able to be trained quickly, their measurements were determined to be accurate and precise and they expressed moderate-to-high confidence in their results. CONCLUSIONS: After brief training, novice clinicians were able to accurately assess JVP in obese patients as compared to measurements made by experienced cardiologists on physical examination. Results suggest that ultrasound may greatly improve novice clinicians\u27 JVP assessment accuracy, particularly in obese patients

Brief training in ultrasound equips novice clinicians to accurately and reliably measure jugular venous pressure in obese patients.

INTRODUCTION/PURPOSE: Measurement of jugular venous pressure (JVP) by novice clinicians can be unreliable, particularly when evaluating obese patients. Measurement of JVP using ultrasound (uJVP) is simple to perform and provides accurate measurements. This study evaluated whether students and residents inexperienced with ultrasound could rapidly be taught to measure JVP using ultrasound in obese patients with the same accuracy as cardiologists measuring JVP via physical examination. Additionally, this study also evaluated the correlation between qualitative and quantitative JVP assessment. METHODS: This prospective, blinded study compared uJVP measurements performed by novice clinicians after brief training to JVP measurements performed by cardiologists (cJVP) on physical examination. Association between uJVP and cJVP was assessed using linear correlation, agreement and bias were assessed using the Bland-Altman analysis and inter-rater reliability of uJVP was assessed using intraclass correlation coefficient (ICC). The association between qualitative and quantitative JVP assessment was assessed using linear correlation. RESULTS: Novice clinicians (n = 16) obtained 34 measurements from 26 patients (mean BMI 35.5) and reported moderate-to-high confidence in all measurements. uJVP correlated well with cJVP (r = 0.73) with an average error of 0.06 cm. The estimated uJVP ICC was 0.83 (95% CI = 0.44, 0.96). Qualitative uJVP had only a moderate correlation (r = 0.63) to quantitative uJVP. DISCUSSION: Novice clinicians often have difficulty assessing JVP on physical examination, particularly in obese patients. Our findings show a high degree of correlation between JVP measurements performed by novice clinicians using ultrasound compared with JVP measurements made by experienced cardiologists on physical examination. Furthermore, novice clinicians were able to be trained quickly, their measurements were determined to be accurate and precise and they expressed moderate-to-high confidence in their results. CONCLUSIONS: After brief training, novice clinicians were able to accurately assess JVP in obese patients as compared to measurements made by experienced cardiologists on physical examination. Results suggest that ultrasound may greatly improve novice clinicians\u27 JVP assessment accuracy, particularly in obese patients

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