Pericardial effusion

Chest Case #12

46 YOF with a pmhx notable for metastatic adenocarcinoma of the breast presents with 3 days increasing dyspnea with exertion and generalized weakness. She denies chest pain, cough/congestion, any fevers/chills. She is currently between chemotherapeutic courses and is not currently undergoing radiation treatment. She presents awake/alert, in no respiratory distress.

History and PhysicalT 97.7 P 105 BP

110/80 O2 96% RR 20

Gen: WDWN, thinCV: Tachycardic,

RR, Pulm: Lungs CTA

bilat, chest wall shows left-sided mastectomy.

Neck – no JVD, trachea midline

Abd – s/nt/ndExt – warm, no

cy/cl/ed

Chest X-Ray

Diagnosis: Pericardial Effusion

-Pericardial effusion causes an enlarged heart shadow that is often globular shaped (transverse diameter is disproportionately increased). 

-A lateral film and close-up of a pericardial effusion showing the anterior mediastinal fat (blue arrows) and epicardial fat (red arrows) separated by a soft tissue stripe ( "fat pad" sign) reflecting the pericardial effusion seen edge-on.

OxygenIV Fluid resuscitationTreatment consists of emergency

pericardiocentesis when there is hemodynamic compromise.

Admission for management of underlying disease state vs. intervention to address fluid collection.

ED Management

Diagnosis Although an effusion is often described as producing a globular-

shaped heart, it is usually not possible to differentiate a pericardial effusion from cardiac enlargement on a chest radiograph

Approximately 250 ml of fluid must be in the pericardium to lead to a detectable change in the size of the heart shadow on PA CXR

small effusions (100–200 mL) may not cause cardiomegaly even though they can cause tamponade when they accumulate rapidly or when the pericardial membrane is stiffened from fibrosis

Pericardial effusion can be definitively diagnosed with either echocardiography (can be bedside in the emergency department in the critically ill patient patient) or CT

Pearls

Presentation In the postoperative patient a pericardial effusion can be a sign

of bleeding, necessitating a return to the OR. Beck's triad (1) systemic hypotension, (2) elevated systemic

venous pressure, and (3) muffled heart sounds is typical of acute tamponade which may be due to abrupt intrapericardial hemorrhage from penetrating trauma, invasive cardiac procedures, or rupture of an ascending aortic dissection or myocardial infarction. The complete triad is rarely present

Tamponade has a spectrum of presentations ranging from circulatory collapse to mildly reduced cardiac output with symptoms of dyspnea and chest or abdominal discomfort depending on the rate of fluid collection.

Pearls

Other findings Pulsus paradoxicus, an accentuated fall in the systolic

pulse pressure (>10 mm Hg) during inspiration, is not present in one-quarter of patients with tamponade.

EKG in the setting of tamponade often shows sinus rhythm with low voltage (QRS amplitude in the limb leads <5 mm) suggestive of tamponade physiology.

Electrical alternans, a more specific sign of tamponade occurs when there is a very large pericardial effusion in which the heart swings during cardiac contraction causing a beat-to-beat variation in the EKG axis (QRS amplitude).

Pearls

Additional Images

Echocardiogram (long axis left parasternal view) confirming a moderate pericardial effusion (1 cm thickness) both anterior and posterior to the heart (arrows).

Additional Images

EKG showing low voltage in the limb leads (<5 mm). There is slight beat-to-beat variation in the QRS amplitude of leads V1, V4 and V5 (electrical alternans).

EKG after pericardiocentesis and drainage of the pericardial effusion showing increased QRS amplitude.