Identification and assessment of the pericardial space
Pericardial effusions are frequently seen in patients with critical illness and are often a key differential diagnosis in hemodynamic decompensation. Although identification of an anechoic space of a potential pericardial effusion can be performed with relative ease, a number of important steps are required to refute other false positives and determine its' significance.
This section will review potential false positives, differentiating pleural vs pericardial, assessment of size and hemodynamic significance, in conjunction with clinical examination. Please come back soon as we will post a video tutorial.
This section will review potential false positives, differentiating pleural vs pericardial, assessment of size and hemodynamic significance, in conjunction with clinical examination. Please come back soon as we will post a video tutorial.
Pericardial vs pleuralThis clip displays key differences between pericardial and pleural effusions on the PLAX view. The descending thoracic aorta is a key landmark, which is often used as a key feature to distinguish pericardial from pleural effusions. Other cardiac views (And even thoracic views) can help you differentiate whether it is strictly pericardial, pleural or both.
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Estimating size The size of a pericardial effusion can be measured by placing a caliper in the echo-free space between the parietal and visceral pericardium at end-diastole. Small and large effusions are likely to be unevenly distributed and measurements can vary widely depending on where the measurement is taken. Unfortunately, little evidence is able to guide measurement of the pericardial space in this instance.
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IVC assessmentThe IVC requires special consideration in assessment of a pericardial effusion. In tamponade, it is very likely to be dilated >2.2cm with minimal collapsibility as RV collapse favors an atrial to caval gradient. In fact, it is very unlikely to have pericardial tamponade in the presence of a flat, collapsing IVC (but can happen in rare/select circumstances).
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Key considerationsPlease keep in mind these key considerations as you assess any pericardial effusion.
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References
Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B, et al. American society of echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: Endorsed by the society for cardiovascular magnetic resonance and society of cardiovascular computed tomography. J Am Soc Echocardiogr [Internet]. 2013;26(9):965-1012.e15.
Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr [Internet]. 2010 Dec;23(12):1225–30.
Nagdev A, Stone MB. Point-of-care ultrasound evaluation of pericardial effusions: Does this patient have cardiac tamponade? Resuscitation. 2011;82(6):671–3.
Olaru C, Dean A, Mulugeta L, Bewtra M, Panebianco N. Bedside echocardiography in the diagnosis of pericardial effusion with increased intrapericardial pressure. Acad Emerg Med. 2015;1):S345.
Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr [Internet]. 2010 Dec;23(12):1225–30.
Nagdev A, Stone MB. Point-of-care ultrasound evaluation of pericardial effusions: Does this patient have cardiac tamponade? Resuscitation. 2011;82(6):671–3.
Olaru C, Dean A, Mulugeta L, Bewtra M, Panebianco N. Bedside echocardiography in the diagnosis of pericardial effusion with increased intrapericardial pressure. Acad Emerg Med. 2015;1):S345.