Ultrasound Education of the Week:
“CLOT” Twist
By: Maria Tama, MD
18 year old M presents for a stab wound to the right lower chest/upper abdomen. Patient arrives with a pulse to the ED, not responsive or alert, being bagged with King tube in place . Primary survey showing 3cm laceration to right upper flank/ lower chest. Pt was tachycardic and hypotensive upon ED arrival. Pt was intubated in ED without any complications.
Scattered images of the fast/echo are shown below... Video attached to email for better viewing.
You see an echogenic structure between the heart and the pericardium. In the video, it seems to be moving separately from the heart.
Patient becomes more hypotensive and tachycardic and ultimately goes into cardiac arrest.
Hemopericardium
Clotted blood in the pericardium, such as in cases of hemopericardium with clot formation, has distinct ultrasound characteristics on a cardiac ultrasound:
Echogenicity:
Fresh blood in the pericardium appears anechoic (black) on ultrasound.
As blood begins to clot, it becomes more echogenic (gray to white, depending on the clot's age and density).
Texture & Mobility:
Clotted blood often appears heterogeneous with a speckled or layered appearance rather than a uniform fluid collection.
It may show strands or fibrinous septations within the pericardial space.
Unlike free-flowing pericardial effusions, clotted blood is more stationary and does not shift with cardiac motion.
Differentiation from Tamponade:
If the clot is significant but not compressing the heart, tamponade physiology may not be present.
If organized thrombus obstructs drainage or continues to accumulate, tamponade can still occur, requiring careful clinical correlation.
Comparison with Free Blood:
Free-flowing pericardial effusions change shape with cardiac movement, whereas clotted blood maintains its structure and may form lobulated or mass-like areas in the pericardial space.
What is the next step?
This patient's rapid decompensation and POCUS findings lead the team to perform a thoracotomy where clots of blood about 200cc were drained. Vitals significantly improved and patient was taken emergently to the OR for exploratory laparotomy showing liver and diaphragm lacerations. Patient is currently in the SICU and improving, extubated and normotensive without any pressor support.
MASSIVE KUDOS TO THE TEAM INVOLVED!!!
***FRIENDLY REMINDER***
PLEASE SAVE IMAGES ON ALL PATIENTS WITH DOCUMENTED POCUS EXAMS IN THE CHART
POCUS SAVES LIVES!
WHAT WE DO MATTERS!