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So let's summarize pericardial effusion.

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It can affect all age and all demographics.

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The data is poor in the overall incidence

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and the prevalence, but it's based upon many different risk factors.

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Patients will present with dyspnea,

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exercise intolerance, chest pain, Beck's Triad, which is really around tamponade.

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It's hypotension, muffled heart sounds and jugular distension.

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And again, much of what we're describing here

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is going to be on the physical examination.

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Very little of this may come across to you

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on the requisition around muffled heart sounds or JVD, and so you may have to ask

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the clinicians in order to put it together.

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Common causes include trauma, malignancy, prior or current ongoing radiation,

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myocardial infarction or inflammatory syndromes.

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The ACR appropriateness criteria

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recommends transthoracic ultrasound as the first line.

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However, chest radiography and CT,

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we're going to see a lot of this and be

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able to comment on this. MRI, you may see as part of other imaging and this is seen

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incidentally, it's not generally something that we're going to do

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first line, particularly in the ED.

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On chest x-ray, effusions that are greater than 200ml are usually visible.

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PA and lateral may show a water bottle-shaped heart.

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And so we've got a couple of examples of something very similar to that.

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The Oreo cookie sign, which is really seen

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on the lateral, which is the fluid between the epicardium and the pericardium

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and the fat in those layers, that is kind of the Oreo cookie sign description,

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but you may see that on the lateral. You may see an enlarging cardiac silhouette

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over time. And then, again, the differential density sign, which is just a band of lower

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density surrounding the heart on the chest x-rays, are things to look out for.

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Not going to spend too much time

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on the EKG other than to say, it can detect pleural fluid at smaller levels and it's

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highly sensitive and specific. On CT and MR,

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again, normal thickness is about 2mm.

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We're going to call small effusions

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in that 3mm to 4mm range, but less than ten.

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Medium is between 10mm and 20mm, and large is anything greater than 20mm.

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So again, 2cm.

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And again, the example that we saw on CT was

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far in excess of this and your eyes were not lying.

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That was a large pericardial effusion.

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The volume of the effusion can be estimated by thickness.

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Generally speaking,

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we're not asked to calculate the volume, but I will generally give some

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of the dimensions of the thickest components and CT and MR are really good

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for detecting loculated pericardial effusions.

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One pitfall may be that cardiomegaly can be mistaken for an effusion or vice versa.

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So it can be hard at times on x-ray in particular, to differentiate dilated

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cardiac musculature myocardium versus a large pericardium because it's filled

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with fluid. And those, obviously, have different implications and treatments.

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The density of the fluid can help

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distinguish between serous and bloody effusions.

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So, always make it a point to measure the fluid and to see where it falls,

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to be able to make a commentary on the components.

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And then finally, in terms of the treatment for pericardial effusion,

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ultrasound guided periodic cardiocentesis is

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the approach versus something where you have dilated myopathy of the cardiac

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muscle or cardiomegaly where you're going to deal with that differently.

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So it's a very important point to differentiate between the two.

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And here are some references.