CXR illustrated a RUL pneumonia and CBC resulted a WBC of 20.5 with 11% bandemia. The patient was eventually placed on BIPAP and Cardiology was consulted for pericarditis. Cardiology refused admission and the patient was admitted to Internal Medicine. Formal echo demonstrated a moderate to large pericardial effusion with strands and echo densities. The patient was started on high dose aspirin, antibiotics and was transferred to the Cardiology service for pericardiocentesis, which drained approximately 2 liters of purulent fluid.
Bedside Echocardiology
Cardiac ultrasound in the ED is a quick and useful procedure. Indications for bedside echo include cardiac arrest, thoracic trauma (both penetrating and blunt force), unexplained hypotension and evaluation of cardiac function. The identification of pericardial effusion is one of the major goals of bedside echo. When an effusion is identified, it is important to look for signs of pericardial tamponade. Tamponade can be identified by the presence of right heart diastolic collapse. During normal cardiac motion the ventricles will expand during diastole and move inward during systole. In the case of tamponade, there is a paradoxical motion of the right ventricle. Instead of expanding during diastole, the right ventricle with collapse inward. This will appear as if an invisible finger is pushing the outer wall of the right ventricle inward. Regardless of the size of the effusion, if right heart collapse is present, emergent pericardiocentesis is warranted.
Over the past twenty years the method of pericardiocentesis has evolved from blind entry to ultrasound guided. The location for entry had been solely from the subxiphiod view, but the left parasternal border may also be used. Direct ultrasound visualization and guidance toward the area of maximum accumulation of fluid and to the area where the effusion is closest to the transducer, decreases the risk of pneumothorax and liver penetration. A 16-gauge needle is used and the catheter may be left in place for further aspiration at a later time.