A 45 year old female with a history of breast cancer presents to the ED with progressive shortness of breath.  ECG and labs are unremarkable.  A bedside US is shown below.  What's the diagnosis?  Scroll down for answer.

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Answer:  Pericardial Effusion with tamponade physiology

Causes:  infection (viral, TB, other), malignant, autoimmune, traumatic, idiopathic

Symptoms: dyspnea, chest pain

Physical exam:  

• pulses paradoxus (SBP drop >10Hg with respiration) (~82% sensitive)
• tachycardia (~77% sensitive)
• JVD (~76% sensitive)
• diminished heart sounds (~28% sensitive)
• hypotension (~26% sensitive)

ECG: classically electrical alternans - beat to beat alternation of amplitude or axis of QRS as heart swings in the pericardial sac.  However ECG can be normal, tachycardia, or low voltage.

Chest x-ray: may show globular shaped heart (Water Bottle Sign) without pulmonary vascular congestion

Cardiac US: Best diagnostic test for diagnosing pericardial effusion - look for right ventricular diastolic collapse.  If unsure, review clip and pause when mitral valve is open.  This is diastole.  If right ventricle is collapsed at this moment this is concerning for tamponade.  Can also use M mode through both mitral valve and right ventricle on parasternal long view to assess if right ventricle is collapsing when mitral valve is open. 

Treatment:  Pericardiocentesis

• equipment: pericardiocentesis tray, gowns/gloves/sterile PPE, US and probe cover (in a pinch can use setile angiocath or spinal needle, or even central line kit)
• perform with ultrasound in parasternal long, subxyphoid or apical 4 osiions; use cardiac probe; measure distance to effusion
• Apical 4 insertion is now more popular; parasternal insertion may hit internal mammary or LAD, subxyphoid may hit liver
• lidocaine for local anesthesia
• draw back while advancing needle in longitudinal plane in order to see entire course under US
• when in pericardial space, you will get flash (bloody, serous, depends on etiology of effusion)
• can flush with agitated saline to see that it is in pericardium and not heart
• after the flash and confirmed in pericardium Seldinger Technique to place catheter - advance wire into space, remove needle, small incision, dilate soft tissue, pass catheter, connect drain, suture.