46 YOF with a pmhx notable T 97.7 P 105 BP 110/80 for metastatic adenocarcinoma of the breast O2 96% RR 20 presents with 3 days increasing dyspnea with Gen: WDWN, thin exertion and generalized CV: Tachycardic, RR, weakness. She denies chest pain, cough/congestion, any Pulm: Lungs CTA bilat, fevers/chills. She is currently between chemotherapeutic chest wall shows left- courses and is not currently sided mastectomy. undergoing radiation treatment. She presents Neck – no JVD, trachea awake/alert, in no respiratory midline distress. Abd – s/nt/nd Ext – warm, no cy/cl/ed
-Pericardial effusion causes an enlarged heart shadow that is often globularshaped (transverse diameter is disproportionately increased).-A lateral film and close-up of a pericardial effusion showing the anteriormediastinal fat (blue arrows) and epicardial fat (red arrows) separated by asoft tissue stripe ( "fat pad" sign) reflecting the pericardial effusion seenedge-on.
Oxygen IV Fluid resuscitation Treatment consists of emergency pericardiocentesis when there is hemodynamic compromise. Admission for management of underlying disease state vs. intervention to address fluid collection.
Diagnosis Although an effusion is often described as producing a globular-shaped heart, it is usually not possible to differentiate a pericardial effusion from cardiac enlargement on a chest radiograph Approximately 250 ml of fluid must be in the pericardium to lead to a detectable change in the size of the heart shadow on PA CXR small effusions (100–200 mL) may not cause cardiomegaly even though they can cause tamponade when they accumulate rapidly or when the pericardial membrane is stiffened from fibrosis Pericardial effusion can be definitively diagnosed with either echocardiography (can be bedside in the emergency department in the critically ill patient patient) or CT
Presentation In the postoperative patient a pericardial effusion can be a sign of bleeding, necessitating a return to the OR. Becks triad (1) systemic hypotension, (2) elevated systemic venous pressure, and (3) muffled heart sounds is typical of acute tamponade which may be due to abrupt intrapericardial hemorrhage from penetrating trauma, invasive cardiac procedures, or rupture of an ascending aortic dissection or myocardial infarction. The complete triad is rarely present Tamponade has a spectrum of presentations ranging from circulatory collapse to mildly reduced cardiac output with symptoms of dyspnea and chest or abdominal discomfort depending on the rate of fluid collection.
Other findings Pulsus paradoxicus, an accentuated fall in the systolic pulse pressure (>10 mm Hg) during inspiration, is not present in one- quarter of patients with tamponade. EKG in the setting of tamponade often shows sinus rhythm with low voltage (QRS amplitude in the limb leads <5 mm) suggestive of tamponade physiology. Electrical alternans, a more specific sign of tamponade occurs when there is a very large pericardial effusion in which the heart swings during cardiac contraction causing a beat-to-beat variation in the EKG axis (QRS amplitude).
Echocardiogram (long axis left parasternalview) confirming a moderate pericardialeffusion (1 cm thickness) both anterior andposterior to the heart (arrows).
EKG showing low voltage in the limb EKG after pericardiocentesis andleads (<5 mm). There is slight beat- drainage of the pericardial effusionto-beat variation in the QRS showing increased QRS amplitude.amplitude of leads V1, V4 and V5(electrical alternans).