Case 8 - Lake of sorrows...
Author: Nish Cherian Reviewer: Nick Mani
A 50-year old male presents to ED with 1-2 weeks of feeling tired and more out of breath. In triage, he is noted to be in AF with a rapid ventricular response (rate of 130bpm), BP 110/70, SpO2 of 89% on room air.
POCUS shows:
Clip 1. PLAX
Clip 2. Subcostal
Clip 3. IVC
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Large pericardial effusion
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A fixed and dilated IVC
RV diastolic collapse can be appreciated in the PLAX view (scroll through the clip to see better).
Other features of tamponade include:
RA systolic collapse
Mitral inflow velocity variation >25% (the sonographic equivalent of ‘pulsus paradoxus’)
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The descending aorta in the parasternal long axis view is a useful anatomic landmark. Pericardial fluid lies anterior to the DA, whilst pleural fluid lies posterior to it.
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A pericardial fat pad. This usually lies anterior to the RV in the PLAX view which may be similarly hypoechoic to fluid and could be mistaken for a pericardial effusion.
Importantly, pericardial fluid will accumulate in dependent regions first. Multiple views are always useful to help corroborate findings.
Case resolution
This patient initially had a CXR showing a cardiomegaly picture with signs of pulmonary congestion. POCUS completely altered management by diagnosing a large pericardial effusion. Whilst he remained haemodynamically stable, we can appreciate some early sonographic signs of tamponade. A pericardiocentesis was performed and the patient was admitted under Cardiology. He was ultimately diagnosed with a pericardial malignancy (an echogenic mass is seen in Clip 2 adherent to the RA).
Appendix
Mitral inflow velocities are shown below. Whilst not the greatest quality of images, it doesn’t show any significant beat-to-beat variation. This is a more advanced skill but worthwhile learning for the more echo enthusiastic people out there!
