Well this looks like a good segue from the previous case of the week, "White Lung on CXR." We also did not perform thoracentesis because there is a more explanatory cause of his symptoms revealed on bedside echo -- Cardiac Tamponade.
Although pleural effusions were present bilaterally, the massive pericardial effusion was clearly causing the patient's unstable hemodynamics. The cardiac structures were so squished one can hardly recognise the chambers (see the subcostal view of the patient's echo). Also, the pleural effusions seen on ultrasound were not that significant.
Generally, on ultrasound, pericardial effusion would appear as anechoic (black) stripe around the heart except when it is hemorrhagic with clots, this time appearing as hyperechoic or bright (as with this case).
(Tip: To easily differentiate simple pericardial effusion from tamponade, look at the IVC -- a distended, non-collapsing IVC points to tamponade while an IVC with respiration-changing size can never be a tamponade)
With anticoagulant on board (he has Internal Jugular Vein thrombosis), we could not perform pericardiocentesis emergently. Instead, the next day, after clexane was stopped, the admitting team inserted a pericardial drain as a palliative measure.
Pericardial effusion sizes: small: <0.5cm, 0.5-2cm: moderate, >2cm: large
Rate of fluid accumulation is more important than the size.
It is best viewed at subcostal/subxiphoid window.
Echo Signs of Tamponade (the first 2 are the most useful):
Diastolic RV collapse (specific)
Systolic RA collapse (sensitive)
Echo Pulsus Paradoxus (Exaggerated MV/TV Inflow Variation): Advanced Technique
Ferrari G, De Filippi G, Elia F, Panero F, Volpicelli G, Aprà F. Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. Crit Ultrasound J. 2014 Jun 7;6(1):8.
Dr. Jerwin D. Pasco
Acute and Emergency Care Centre, Khoo Teck Puat Hospital. Singapore