Download - Pericardial and Pleural Effusions
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09/02/2011
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PERICARDIAL AND PLEURAL EFFUSIONS
Stephen Glen
Clinical features of tamponade
Becks triad hypotension, raised JVP, quiet heart sounds
Pulsus paradoxus (>10 mmHg drop in BP with inspiration)
All difficult in acutely ill patients
Echo signs to look for
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IVC The best views to diagnose, are also the best to drain A4Ch
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Subcostal Parasternal to diagnose only
The size of the effusion
Useful for drainage (> 2 cm)
Not always associated with compression
Rapidity of onset more important
You dont want to see this during pericardial tap..
Case
52 yrs, female
Increasing dyspnoea and fatigue
Previous mastectomy for breast CA
On regular tamoxifen
Examination
BP 130/80
P 90/min
JVP elevated
No respiratory variation in BP or pulse
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A4Ch Immediate drainage required?
1. Yes
2. No
3. Unsure
Management
No clinical evidence of tamponade
CT chest effusion only, no mass lesion
Drained for diagnostic and therapeutic effect
Cytology recurrent of breast CA
Subsequent chemotherapy (no recurrence of effusion)
Case
Female, 57 yrs
Sudden collapse with associated dyspnoea
Background of pleuritic chest pain, myalgia
Known HIV +ve
On retroviral therapy
Examination
GCS 14/15
SaO2 96% (15 litres)
BP 94/50 -> 75/40 on inspiration
Pulse 90-130 /min
HS inaudible
JVP elevated
Chest clear
A4ch
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Subcostal Immediate drainage required?
1. Yes
2. No
3. Unsure
Pericardiocentesis, or love in the procedure room?
Progress
Successful drainage
Cytology confirmed Kaposis sarcoma a cause of haemorrhagic pericardial effusion in HIV positive patients
Mediastinoscopy directed pericardial window
Confusing case
62 yrs, male
Known lung CA due for resection (right apex)
Sudden onset dyspnoea and palpitations
Associated left pleuritic chest pain
Recent preoperative chemotherapy
No other PMH
Examination
Unwell, GCS 15
SaO2 81% (15 litres)
p130/min (sinus)
BP 80/40
HS inaudible
Chest tachypnoeic, no crackles heard
Abdo normal
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Focused echo, A4ch Which is true?
1. There is right atrial collapse
2. There is right ventricular collapse
3. There is left atrial collapse
4. There is no echo evidence of tamponade
5. Unsure
A4ch, colour Subcostal
PSAX Immediate drainage required?
1. Yes
2. No
3. Unsure
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Management
CTPA confirmed central pulmonary embolism
Pericardial effusion considered contraindication to thrombolysis
Anticoagulated with heparin
Effusion did not increase in size but right atrial collapse developed as pulmonary artery pressure fell, clinical evidence of tamponade
Pericardial drain inserted
Malignant cells identified in aspirate
Case
71 yrs, female
Severe dyspnoea
Background of COPD with home nebuliser
PMH hypertension
Rx irbesartan, salbutamol, atrovent, recent prednisolone, aspirin, simvastatin
Smoker
Examination
GCS 15
SaO2 88% (24%, 2 litres)
BP 168/90
JVP not visible
HS inaudible
Chest silent chest (left), widespread wheeze (right)
Abdo normal
Focused ultrasound, A4ch
Is this pericardial or pleural? 1. Pericardial
2. Pleural
3. Both
4. Unsure
A4ch, lateral view
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Management
CXR confirmed left lung whiteout
Ultrasound guided drain insertion
Haemorrhagic exudate
Cytology bronchial CA
Hilar lesion identified after drainage on CT
Chemotherapy started
Case
38 yrs, male
Known Marfan syndrome
Aortic root and valve replacement 3/12 ago
Good postop recovery
Dental work 3/52 ago without antibiotic prophylaxis
Admitted in extremis
Examination
GCS 8/10 (E2M4V2)
38.4C
SaO2 91% (15 litres)
BP 60/?
P109/min (sinus)
HS loud systolic murmur (aortic area)
Chest reduced air entry left base and mid zone
Focused echo, PLAX
Is this pericardial or pleural? 1. Pericardial
2. Pleural
3. Both
4. Unsure
PSAX
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Management
CT thoracic aortogram confirmed dehiscence
Contrast leak into mediastinum, pericardium, lung
Immediate cardiac surgery to repair
Swabs at surgery confirm strep. Bovis growth
6/52 inpatient antibiotic therapy
Subsequent echo
PLAX during longterm follow-up
Case
19 yrs, male
Sharp left parasternal chest pain
Recent myalgia, fever, nausea, diarrhoea
No other PMH
No regular Rx
Thrombolysis or pPCI?
1. Thrombolysis in A&E
2. Transfer for pPCI (about 60 mins journey)
3. Neither
4. Unsure
Focused echo, A4ch
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PSAX PLAX
Is this pericardial or pleural? 1. Pericardial
2. Pleural
3. Both
4. Neither
5. Unsure
Management
Clinical pericarditis
Started on regular ibuprofen and colchicine
Inflammatory markers
Repeat echo in 7 days
Manage as outpatient
Case
Male, 52 yrs
Chest, back and abdominal pain
PMH Hypertension, AF
Rx Simvastatin, perindopril, warfarin, diltiazem
Smokes 60/day
No alcohohohol for at leasht a day
(according to patient)
Examination
Pale, unkempt
GCS 14
SaO2 98% (air)
BP 90/48
P58/min (sinus)
HS included harsh ejection systolic murmur
Chest clear
Abdomen- diffuse guarding, no bowel sounds
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Focused echo, PLAX Is this pericardial or pleural? 1. Pericardial
2. Pleural
3. Both
4. Neither
5. Unsure
PLAX, colour Abdomen
Abdomen Abdomen
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Management
CT aorta (root to knees)
Ascending aortic dissection, false lumen to iliacs, infrarenal aneurysm
Contrast into mediastinum, pleura
Accepted for surgery
Anticoagulation reversed
Limited surgical repair to dissection flap
Continues medical therapy