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This review article discusses two clinical cases of patients presenting to the emergency department with pericardial effusions. The role of bedside ultrasound in the detection of pericardial effusions is investigated, with special attention to the specific ultrasound features of cardiac tamponade.

Through this please click for source, clinicians caring for patients with pericardial effusions will learn to rapidly diagnose this condition directly at When Do You Have Hookup Ultrasound bedside. Clinicians will also learn to differentiate between simple pericardial effusions in contrast to more complicated effusions causing cardiac tamponade.

Indications for emergency pericardiocentesis are covered, so that clinicians can rapidly determine which group of patients will benefit from an emergency procedure to drain the effusion.

The diagnosis of cardiac tamponade as a result of pericardial effusion was originally described in by Dr. Claude Beck as the clinical exam triad of muffled heart sounds, jugular venous distention, and hypotension.

However, clinicians have since recognized that patients with symptomatic pericardial effusions may not display these classical clinical examination findings. Furthermore, these cases will demonstrate how bedside echocardiography can help differentiate between patients with a compensated effusion from those with tamponade physiology.

A year-old male with a history of metastatic prostate cancer currently undergoing palliative chemotherapy presents to the ED complaining of weakness, fatigue, and shortness of breath.

Initial vital signs were as follows: On physical examination the patient appears ill, with respiratory distress. Cardiac auscultation is significant for tachycardia. Jugular venous distention is present to the angle of the mandible. Electrocardiogram EKG reveals a low voltage tracing with sinus tachycardia.

Bedside ultrasound reveals a circumferential pericardial effusion, with a hyperdynamic left ventricle.

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Closer examination demonstrates collapse of the right ventricle during diastole [ Figure 1 ]. Furthermore, the inferior vena cava IVC is distended, with loss of normal respiratory variation [ Figure 2 ]. A year-old man with congestive heart failure presents to the ED complaining of progressive shortness of breath over the last month.

Initial vital signs are as follows: The patient appears comfortable. Clinical examination is remarkable for quiet heart sounds and rales at the left base. EKG shows normal sinus rhythm with low voltage.

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Chest radiography reveals cardiomegaly and a left side pleural effusion. Bedside echocardiography demonstrates a circumferential pericardial effusion with depressed left ventricular function. On further examination, there is subtle evidence of collapse of the right atrium during diastole, without simultaneous collapse of the right ventricle [ Figure 3 ].

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The IVC is small in diameter, read more normal respiratory variation [ Figure 4 ]. The initial examination of the heart via transthoracic echocardiography should be performed utilizing one of the standard four views: A pericardial effusion will appear as a dark, or anechoic, stripe surrounding the heart. Smaller effusions will appear as a thin stripe inside the pericardial space, often not extending fully around the heart and usually layering out posteriorly with gravity.

Small effusions should not be confused with a pericardial fat pad, which will appear as an isolated dark area with brighter speckles, located anteriorly. This is more common with post-cardiac surgery patients.

One potential pitfall in the diagnosis is that pleural effusions may be confused with pericardial effusions. The parasternal long-axis view can be used to accurately define the effusion.

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The descending aorta will appear as a cylinder posterior to the mitral valve and left atrium. The posterior pericardial reflection is located anterior to this structure. Fluid anterior to the posterior pericardial wall is pericardial, while fluid located behind is pleural [ Figure 6 ]. Pericardial effusions can result in hemodynamic instability as the pressure in the thick fibrinous pericardial sac increases, reducing cardiac filling.

Pericardial effusions as small as 50 When Do You Have Hookup Ultrasound may cause acute tamponade. Conversely, in chronic conditions, the pericardium may stretch to hold large effusions without tamponade. As pericardial effusions accumulate and the pressure in the sac rises, the lower pressure circuit of the right side of the heart is affected first. Cardiac tamponade is thus classically defined as the collapse of either the right atrium or the right ventricle during the diastolic phase of the cardiac cycle.

Ultrasound findings can range from a subtle inward serpentine diastolic deflection of the right atrial or right ventricular free wall to complete diastolic collapse of the chamber wall. When examining a patient for potential tamponade, it is important to distinguish between the physiologic contraction of the heart during systole from pathological collapse during diastole.

Right atrial collapse may be especially difficult to identify, as atrial systole can often mimic diastolic collapse, especially in the tachycardic patient.

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Thus, it is crucial to accurately identify the diastolic cardiac phase from systole. One method to better identify diastole is to employ real-time EKG monitoring while performing echocardiography. Many bedside ultrasound machines now allow hookup of EKG leads to the patient When Do You Have Hookup Ultrasound simultaneous display on the ultrasound screen.

Diastolic chamber collapse should be correlated with the EKG period following the T wave and click from systolic contraction timed with the P wave and QRS complex. A second method is to directly observe the opening of the mitral valve to better estimate the onset of diastole. After first recording a video clip of the entire cardiac cycle, the clinician can then go through each frame manually. Then by scrolling through these images, diastole can be recognized as the period between mitral valve opening and closure.

Collapse of the right-sided heart chambers during this determined period represents tamponade physiology.

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The third technique is to use M-mode Doppler to trace simultaneous movement of the mitral valve and the right ventricular free wall. This is obtained by placing the M-mode cursor in an axis across the right ventricular free wall to the anterior leaflet of the mitral valve.

This technique allows accurate assessment of chamber dynamics during diastole by timing the opening of the mitral valve to any posterior deflection of the ventricular wall, representative of tamponade physiology.

This is done by examining both the absolute size of the IVC and its variation in size throughout the respiratory cycle. A simple method of identifying the IVC is to first view the heart in the subxiphoid four-chamber view.

The When Do You Have Hookup Ultrasound is click at this page angled inferiorly, imaging the IVC as it joins the right atrium. The IVC should be examined inferiorly, past the point of confluence of the hepatic veins, usually about 2 cm distal from the heart.

This allows the clinician to determine the size of the IVC in the short-axis view, potentially providing the most accurate measurement by avoiding the cylinder effect. The IVC can also be evaluated in the long-axis view by rotating the probe to a position with the indicator oriented vertically. By moving the probe slightly toward the patient's right, the IVC should come into view adjacent to the aorta.

The finding of IVC plethora with loss of respiratory collapse, signifying elevated CVP, is confirmatory echocardiographic evidence of tamponade.

Using Doppler mode, changes in blood flow across the cardiac valves can be seen that indicate cardiac tamponade. Normally, there is some variation in flow across the valves due to the respiratory cycle. During cardiac tamponade, this respiratory variation in blood flow across the valve is exaggerated. This can be best visualized by imaging at the level of the tricuspid valve and looking for a larger inflow of blood during inspiration as compared to expiration.

In the two clinical scenarios described above, both patients had large pericardial effusions. However, bedside echocardiography allowed for accurate determination of the patient who had acute cardiac tamponade necessitating an emergent pericardiocentesis from the patient who had a compensated effusion, where delayed pericardiocentesis by cardiology could be performed.

The patient in the first case is clinically in a state of shock. These clinical findings, in combination with the bedside echocardiography findings of a circumferential effusion with right atrial and ventricular diastolic collapse and a plethoric IVC with loss of respiratory variation, represent an obstructive shock state due to tamponade.

In the unstable patient with clinical and echocardiographic findings of tamponade, an emergent pericardiocentesis is indicated. Traditionally, pericardiocentesis has been performed via the subxiphoid approach. More recently, it has been found that the optimal approach was determined by using echocardiography.

While the patient When Do You Have Hookup Ultrasound in the second clinical scenario appears clinically stable, the situation can actually be more challenging to manage. The patient's presentation suggests an exacerbation of congestive heart failure.

However, bedside echocardiography demonstrated a large, circumferential pericardial effusion. The question of whether rapid pericardiocentesis was indicated was best answered by further evaluation of the ultrasound findings.

While subtle right atrial diastolic collapse was noted, there was no simultaneous collapse of the right ventricle or plethora of the IVC.

These ultrasound findings were consistent with early, or compensated, tamponade physiology. In this case, there was time for a cardiology consultation and more detailed specialty evaluation. Due to the absence of definitive ultrasound features of tamponade at that time, the patient was admitted to the cardiac care unit with plans for close observation and a scheduled pericardiocentesis for the next day.

In conclusion, bedside echocardiography has been shown to rapidly and reliably diagnosis pericardial effusion and tamponade. Clinicians caring for these patients can rapidly incorporate these ultrasound techniques into their practice to more When Do You Have Hookup Ultrasound diagnose please click for source tamponade and to potentially achieve improved treatment outcomes.

National Center for Biotechnology InformationU. J Emerg Trauma Shock. Received Oct 11; Accepted Oct This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles PMC. Abstract This review article discusses two clinical cases of patients presenting to the emergency department with pericardial effusions.

Cardiac tamponade, echocardiography, pericardial effusion, pericardiocentesis, ultrasound. Acute pericardial tamponade diastolic collapse of the right ventricle is noted on subxiphoid view. Plethora of inferior vena cava. Case 2 A year-old man with congestive heart failure presents to the ED complaining of progressive shortness of breath over the last month. Pericardial effusion with early tamponade.

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The right atrium is noted to have diastolic collapse, as timed with the T wave on electrocardiogram monitoring at bottom. Collapse of inferior vena cava.

Ultrasound findings Evaluation of the pericardium The initial examination of the heart via transthoracic echocardiography should be performed utilizing one of the standard four views: