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EMGuideWire's Radiology Reading Room: Pericardial Effusion

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EMGuideWire's Radiology Reading Room: Pericardial Effusion

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Spontaneous Pericardial Effusion and is brought to you by Chelsea Wilson, MD, and Emily Lipsitz, PA-C.

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Spontaneous Pericardial Effusion and is brought to you by Chelsea Wilson, MD, and Emily Lipsitz, PA-C.

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EMGuideWire's Radiology Reading Room: Pericardial Effusion

  1. 1. Pericardial Effusion Case Studies Chelsea Wilson, MD; Emily Lipsitz, PA-C Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Charlotte, North Carolina Michael Gibbs, MD, Faculty Editor The Chest X-Ray Mastery Project™
  2. 2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and all ages have been changed to protect patient confidentiality.
  3. 3. Process • Many are providing clinical cases and presentations are then shared with all contributors on our departmental educational website. • Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. • We will review a series of CXR case studies and discuss an approach to the diagnoses at hand: PERICARDIAL EFFUSION.
  4. 4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. Before Now 33-Year-Old With A Complex Malignancy Now Presents With Dyspnea.
  8. 8. Before Now 33-Year-Old With A Complex Malignancy Now Presents With Dyspnea. The Cardiac Silhouette Now Looks Bigger And More Globular
  9. 9. ED Bedside Ultrasound: Pericardial Effusion * * * * 33-Year-Old With A Complex Malignancy Now Presents With Dyspnea.
  10. 10. 78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea.
  11. 11. Before Now 78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea.
  12. 12. Before Now 78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea. The Cardiac Silhouette Now Looks Bigger And More Globular.
  13. 13. * * * * * * A Chest CT Obtained To Rule Out Pulmonary Embolus Instead Reveals A Large Pericardial Effusion. 78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea.
  14. 14. On Presentation Post-Procedure 78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea.
  15. 15. On Presentation Pericardiocentesis  300 cc of fluid removed  Cardiac silhouette smaller Post-Procedure 78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea.
  16. 16. Thoughts On Pericardial Effusions • Think about the possibility of a pericardial effusion in patients with chest pain, dyspnea, syncope or pre-syncope. • Slowly accumulating pericardial effusions stretch the pericardium and enlarge the cardiac silhouette on CXR. A careful comparison with old CXRs is helpful. • Rapidly accumulating pericardial effusions (e.g.: stab wounds, blunt trauma) typically ARE NOT associated with cardiac silhouette enlargement on CXR. • The liberal use of bedside point-of-care ultrasound is diagnostic.
  17. 17. See You Next Week!Chest X-Ray Two Weeks Ago History Of Pacemaker Placement At An Outside Facility Two Weeks Ago.
  18. 18. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago. Now Presents To The CMC ED With Weakness And Dyspnea.
  19. 19. Large Pericardial Effusion Due To Pacemaker Lead Perforation Of The Right Ventricle. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago. Now Presents To The CMC ED With Weakness And Dyspnea.
  20. 20. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago.
  21. 21. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago. ED Bedside ECHO: Large Pericardial Effusion (*) Cardiac Apex *** * **
  22. 22. Pericardiocentesis And 1300 cc Of Bloody Fluid Is Removed History Of Pacemaker Placement At An Outside Facility Two Weeks Ago
  23. 23. Prospective observational study of 968 patients undergoing heart rhythm device implantation or upgrade who underwent echo before and 24h after operation: • Pericardial Effusion documented in 98 patients (10%) • 1.5% (n=14) of whom progressed to cardiac tamponade requiring pericardiocentesis in 86% (n=12) and surgical treatment in 14% (n=2)
  24. 24. Risk Factors: Female gender and antiplatelet therapy Protective Factor: Previous cardiac surgery Circulation Journal Vol.77, pp 975-981, April 2013
  25. 25. • Utilization of ventricular and atrial screw—in leads were associated with an increase risk of post-procedural Pericardial Effusion (PE) • Specifically an atrial active fixation lead was used in 86% of patients who subsequently developed large PE with tamponade physiology Circulation Journal Vol.77, pp 975-981, April 2013
  26. 26. 60-Year-Old With Dyspnea. Enlarged Cardiac Silhouette.
  27. 27. 60-Year-Old With Dyspnea. ED Bedside ECHO: Pericardial Effusion
  28. 28. 27-Year-Old With One Week Of Chest Pain and Dyspnea Transferred From An Outlying Hospital After Chest CT
  29. 29. 27-Year-Old With One Week Of Chest Pain and Dyspnea.
  30. 30. 27-Year-Old With One Week Of Chest Pain and Dyspnea. Chest CT Obtained: Large Pericardial Effusion
  31. 31. 27-Year-Old With One Week Of Chest Pain and Dyspnea. ECHO
  32. 32. 27-Year-Old With One Week Of Chest Pain and Dyspnea. Pericardial Effusion: Pericardiocentesis = 250 cc Straw-Colored Fluid Cardiac Apex ** * *
  33. 33. Pericardial effusions size is based on simple semiquantitative echocardiographic assessment of cardiac effusion measured in mm in diastole European Heart Journal, Vol. 34, pp 1186-1197, 2013
  34. 34. 8 Months Ago Today 27-Year-Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea.
  35. 35. Massive Pericardial Effusion 27-Year-Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Progressive Dyspnea.
  36. 36. Massive Pericardial Effusion 27-Year-Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea.
  37. 37. Massive Pericardial Effusion * * * * ** * * * * 27-Year-Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea.
  38. 38. Pericardial Drain In Place 2.7 Liters Of Fluid Removed! 27-Year-Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Progressive Dyspnea.
  39. 39. 27-Year-Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Progressive Dyspnea. 3 Months After Pericardial Drainage.
  40. 40. Three variables were independently predictive of pericardial effusion in late-stage CKD patients: • Heart rate at admission, serum potassium and corrected calcium level • Presence of any one of these abnormalities: demonstrated 66% specificity and 55% sensitivity in identifying patients with pericardial effusion • Presence of any two of these abnormalities: demonstrated 97% specificity and 18% sensitivity in identifying patients with any pericardial effusion Clinical Cardiology, Vol. 41, pp 660-665, 2018
  41. 41. 73-Year-Old Female With Progressive Dyspnea
  42. 42. 73-Year-Old Female With Progressive Dyspnea Massive Pericardial Effusion
  43. 43. 73-Year-Old Female With Progressive Dyspnea 73-Year-Old Female With Progressive Dyspnea * * * * * Massive Pericardial Effusion
  44. 44.  Rapidly accumulating pericardial effusions cause swift increases in intrapericardial pressure and tamponade physiology.  Slowly accumulating pericardial effusions gradually distend the pericardium and symptoms can be delayed.
  45. 45. If You Have Interesting Cases Of Pericardial Effusion, We Invite You To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To: michael.gibbs@atriumhealth.org Your De-Identified Case(s) Will Be Posted On Our Education Website And You And Your Institution Will Be Recognized!

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