09/02/2011

1

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

1

2

3

IVC The best views to diagnose, are also the best to drain A4Ch

09/02/2011

2

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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3

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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5

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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8

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

09/02/2011

10

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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11

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