A 47-year-old male presented to the ED with a chief complaint of progressive shortness of breath x 3 weeks. Records from an outside hospital had shown multiple nodules in the thoracic region. He had been experiencing continued dyspnea at rest, worsened with activity. Review of systems was positive for fatigue, unexpected weight changes, non-productive cough, diffuse chest pain, and lower abdominal pain. He denied fevers or hemoptysis as well as any personal or familial history of cancer.
On physical exam, he was afebrile with vitals within normal limits and in no acute distress. Cardiovascular exam was unremarkable; however, lung exam showed bilateral wheezes in the upper lobes and a palpable lymph node in the right axilla. Chest x-ray showed a large anterior mediastinal mass with a left-sided pleural effusion. Bedside ultrasound findings showed a large anterior mass, a large pericardial effusion (Fig 1), bilateral pleural effusions (L > R), and a collapsible IVC with inspiration.
This patient was admitted and later found to unfortunately have metastatic T-cell lymphoblastic lymphoma. CT surgery recommended no surgical intervention with regards to the pericardial effusion. He was started on chemotherapy and follow-up notes stated his respiratory symptoms and pericardial effusion improved with decreased IVF and Lasix.
Learning Tidbits:
•Remember: It is the rate of accumulation rather than size that causes tamponade. Chronic conditions (e.g. malignancy) may allow the pericardium to accommodate large effusions without tamponade.
– As fluid pressure accumulates within the pericardial sac; the right side of the heart is affected first as it is a lower pressure circuit.
•Pericardial effusion/tamponade ultrasound findings:
-Black fluid (anechoic) in the pericardial space.
-May be circumferential or localized.
-IVC may be plethoric (dilated) with loss of respiratory variation.
•Cardiac tamponade = collapse of either the right atrium or the right ventricle during cardiac diastole.
-Free wall may exhibit a wavy/trampoline-like motion (Fig 1a)
•Pericardial effusion vs Pleural effusion (Fig 2):
-Locate the descending aorta with the parasternal long axis view (posterior to mitral valve and appears cylindrical).
-Fluid anterior to posterior pericardial wall & aorta = pericardial effusion
-Fluid posterior to pericardial wall & aorta = pleural effusion
Extra Knowledge Bolus:
•How can I differentiate physiologic right atrial systole from pathologic diastolic collapse?
Option 1) Use real-time EKG monitoring while doing the ultrasound.
-Collapse following EKG T wave → diastolic collapse
-“Collapse” within EKG P wave → systolic contraction
Option 2) Directly observe diastolic chamber collapse
-Mitral valve opening & closure = diastolic period
-Collapse of right-sided heart chambers during this time → tamponade physiology
Option 3) M-mode Doppler → trace simultaneous movement of mitral valve and RV free wall
-Place M-mode cursor across RV free wall and anterior leaflet of mitral valve
Resources:
•“The Role of Bedside Ultrasound in the Diagnosis of Pericardial Effusion and Cardiac Tamponade” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299160/
•http://www.criticalecho.com/content/tutorial-8-assessment-pericardial-disease
-Lizzy Kim, MS4