Pericardial effusion

April 8, 2016

Bedside US Procedure: Pericardial drainage – Pearls! #FOAMed, #FOAMcc, #FOAMus

So here is a video of a pericardial drain placement for pre-tamponade in a 33 yr old man, presumptively for a viral pericarditis (cultures and cytology pending).  In this case, the approach was subxiphoid, because this offered a large pocket of fluid with little or no risk of hitting the RV. The apical approach would have been more risky. Due to technical issues, the video only starts once the guide wire is already in place, but there are a couple of teaching points worth sharing nonetheless.

First, it is useful to confirm guide wire placement prior to dilating. Secondly, in cases such as this where the distance to the pericardium is more than a couple of centimetres (it was about 6 cm here), it is nice to be able to confirm under real-time that the dilator is indeed in the intended area. Because the guide wire is highly echogenic, and the dilator is not, one can see the proximal part of the guide wire “disappear” which indicates that the dilator has covered it, now visibly in the effusion. Once the pigtail is  inserted over the guide wire, final confirmation can be obtained by injecting back thru the pigtail and seeing echogenic material (due to minute amounts of air) appear in the pericardium. This is known as the Ajmo sign.

Cheers!

 

Philippe

August 27, 2014

Pericardiocentesis for tamponade w/bedside ultrasound: Procedure Video. #FOAMed, #FOAMcc, #FOAMus

So this case was interesting on a couple of levels.

A 76 year old woman presented to the ER with a complaint of abdominal discomfort and was admitted with a diagnosis of pneumonia and lower abdominal cellulitis. She had a history of diabetes, obesity and remote oral cancer which had been treated 6 yrs ago.  The next morning, while still in the ER awaiting a ward bed, she had a hypotensive episode, and fortunately the ER doc on shift grabbed an ultrasound probe and took a look, calling me a few minutes later with a diagnosis of tamponade. She was absolutely correct. I saw and echo’d her shortly after:

The first two clips show the IVC, which is distended with minimal variation. This should prompt the bedside sonographer to anticipate downstream pathology (except for iatrogenic volume overload and renal failure…).

The subsequent clips show subxiphoid views (and one clip of the associated left pleural effusion) showing a significant pericardial effusion and difficult to distinguish cardiac chambers.

Clinically, she was dyspneic, uncomfortable, HR 115, BP 130’s systolic (in ER in 80’s then got some fluid). Her heart sounds were not particularly quiet, and her JVP was difficult to assess due to obesity.

Here is the drainage video:

Her abdominal pain resolved very rapidly, her breathing improved and vitals stabilized.

Pathology is still pending, but bloody effusions commonly include malignancy, tuberculosis, but also simple viral paricarditis.

So I think this is a great case for the argument of integrating ultrasound into physical examination rather than as an ancillary test.  Because she didn’t present with a predominant hypotensive or respiratory component, the diagnosis wasn’t seriously entertaine, and obesity, body habitus and pleural effusion undoubtedly made physicians overlook the cardiomegaly. However, in my opinion and that of most bedside sonographers, abdominal pain warrants an abdominal us exam, and the distended IVC would have prompted at least a quick cardiac assessment, and the effusion would have been noted immediately.

In my CC/IM practice, hardly anyone escapes the probe, as cardiopulmonary and abdominal status is hardly ever irrelevant to me…

cheers!

 

Philippe

October 9, 2013

Bedside ultrasound clip quiz 1 – #FOAMed, #FOAMcc

62 year old with weight loss, tachycardia and progressive dyspnea…what do you see?

scroll below!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This was a case of pre-tamponade/tamponade.  Here is a view a few minutes later, with the guidewire in. This was a case of malignant pericardial effusion.