Pericardial Effusion - Seen one lately?

A 60 year old man presents with shortness of breath on exertion.  You work him up, but chest x-ray, spirometry, ECG, and labs (troponin and D-dimer) are all normal.  Send him home, I guess...

Have you considered occult pericardial effusion?  I have diagnosed about six unexpected pericardial effusions in the last year, and I have learned a few lessons:

1) this is not as rare a diagnosis as you think
2) patients can look really good, even with impending tamponade

This is an easy diagnosis to miss, but in 2013, I don't think that's acceptable anymore.  Any well-trained emergency physician should be thinking about it and has a tool at hand to make the diagnosis quickly and cheaply.

The first video here is in the subxiphoid view.

The next video is the same patient, showing the effusion in the parasternal long.

The third video is from a different patient.  Notice here how the right ventricular wall is collapsing inward at end-diastole.  This is an echocardiograhic sign of tamponade.  For the clinician, tamponade should be a clinical diagnosis, but if you see this at the bedside, be worried!

Occult pericardial effusion is not hard to diagnose.  You just need to think of it, and be liberal in your use of PoCUS.  Unexplained dyspnea, weakness, hypotension, or tachycardia?  Get out your probe!

An unexpected finding...

Great Ultrasound Case

A recent case of mine.

HPI:  Fifty yo man presents complaining of constipation.  It started five days before, and he attributes it to new medications.  Two days before that he had been seen at a walk-in-clinic with cough and shortness of breath.  A chest x-ray had been done (I did not have the results).  He had been told he had infection and fluid on the lungs, and started on clarithromycin and furosemide.  Now, he feels his breathing is better but he feels constipated and his belly feels distended.

Something smells fishy here.

PMHx: smoker, nil else

Exam: All vitals normal.  Patient in no distress and looks generally well.  Abdomen distended but non-tender, nothing else noted.

POCUS saves the day:
Abdomen: lots of free fluid
Cardiac: large pericardial effusion with signs of RV collapse.

He is moved to a monitored area, where an ECG shows electrical alternans and he is found to have a pulsus paradoxus of 20 mmHg.

Diagnosis: pericardial tamponade.  He is admitted to cardiology.  He is ultimately found to have an unrecognized lung mass and the effusion is malignant.

Share your recent great ultrasound cases and we will post them here!  - James