1 year earlier

37yo male with unknown PMH presented s/p jump in front of train tracks (suicide attempt). Hypotensive and tachycardic upon arrival. CXR unremarkable. PXR showing R hip dislocation, R acetab fracture, and L sacral ala fracture. Went to CT scan for trauma set 5, significant for R hip dislocation, R acetab fracture, L sacral ala fracture, minimal pneumomediastinum, L5 TP fx, L1, L2 TP fx, T7 SP fx, and pericardial effusion. Became tachycardic to 150s in ED and was taken to OR emergently for pericardial window which was negative for blood, positive for clear fluid which was sent for path. 40 year old male

The cause of his symptoms was initially unclear. On arrival, he was ill-appearing, diaphoretic, and tachycardic to the 160s. His blood pressure and mental status were normal. His abdomen was massively distended but soft and nontender. He had faint wheezes bilaterally but was speaking in full sentences with no respiratory distress. His EKG showed sinus tachycardia. Her portable chest x-ray showed a large lucency surrounding the mediastinum. Bedside echo was limited by difficult acoustic windows. He was ordered for labs and 2 L of IV fluids and sent for a CTPA (considering his history of PE) and a CT abdomen pelvis. These showed a large intra-abdominal fat-containing lesion concerning for a liposarcoma and herniation of colon into the pericardial space through a 1.8 cm defect with secondary perforation leading to large volume pneumopericardium with air-fluid levels. He was ordered for blood cultures and covered broadly with vancomycin and Zosyn. General surgery and cardiac surgery were consulted. Per chart review, he had a pericardial window during his last admission, and the mass-effect of his intra-abdominal lesion likely caused herniation of intra-abdominal contents through the defect in his diaphragm, which likely became strangulated and perforated. He had a brief episode where he developed acute respiratory distress. He was placed on a nonrebreather. His O2 sat and blood pressure were normal, but he was persistently tachycardic and diaphoretic. At that point, his tachycardia had not improved with IV fluids, and I thought he was exhibiting tamponade physiology from his pneumopericardium. I discussed this case with general surgery and cardiac surgery, who took him emergently to the OR for intervention. He was given PCC for reversal of his Eliquis prior to the procedure.