This is a 35 y.o. male I saw while on the MICU service. He originally presented to the Emergency Department with a chief complaint of worsening mental status. Further investigation revealed a history of EtOH cirrhosis and the patient was admitted for hepatic encephalopathy. A parasternal long axis view of the heart in the MICU showed an anechoic area at the posterior left ventricle which was presumed to be fluid accumulation. The fluid is anterior to the descending aorta and posterior to the coronary sinus. No evidence of a swinging heart sign was identified and no diastolic collapse of the right ventricle could be seen. His IVC was greater than 2 cm and demonstrated minimal respirophasic variation. This patient was ventilated at the time this image was taken. Of note, multiple B lines could be seen at R1, R2, L1, and L2. So, does this patient have a pleural effusion or a pericardial effusion?
The key here is structure identification. As can be seen in the image, the fluid is posterior to the coronary sinus but anterior to the descending aorta ( Not well seen in this picture but definitely there). This pattern of fluid accumulation is diagnostic of a pericardial effusion. Had the fluid been posterior to the descending aorta, one could assume that this patient was suffering from a pleural effusion.
Matthew Stevenson, MS4