0:00

This is a case of a 60 year old gentleman who

0:03

presents to the Ed complaining of

0:06

chest pain shortness of breath and dyspnea

0:09

on exertion.

0:11

Again going through our steps looking at

0:14

the lung Fields. He's not taking the greatest

0:17

of inspiration. And so there are probably some hypoventilary changes

0:20

with some areas of atelectasis bilaterally.

0:24

Maybe there's some Adele. This is in this area.

0:27

the midline structures heart mediastinum

0:30

the trachea is a little

0:33

deviated and that's likely secondary to

0:36

vascular structures here the aortic knob

0:38

but the thing that stands out.

0:40

Most significantly on this examination is

0:43

it's very large globular almost water

0:46

bag or water bottle shaped heart. That's

0:49

obviously too big and so

0:52

while you might be tempted to say, hey, this guy

0:55

has got a big heart recognize that there are

0:58

components here. There's The myocardium the

1:01

heart itself. There's also the pericardium

1:04

and whether or not we're talking about a big heart or an

1:07

enlarged cardiac silhouette because we

1:10

don't necessarily know what's really enlarged. So I tend to

1:13

be very specific in my terminology to say that this is an enlarged

1:16

globular cardiac silhouette and

1:19

a differential would include pericardial effusion

1:22

or intrinsic myocardial facilitation

1:25

or cardiomegaly just to

1:28

round things out we want to make sure that we're not missing anything on

1:31

the bones. So again, we're going to run the ribs to

1:34

make sure that there's nothing abnormal. They're no lesions. There's

1:37

no fractures. We're looking at the clavicles. We'll

1:40

take a look at the shoulders.

1:42

And what we can see of the spine and everything

1:45

looks normal there.

1:47

The soft tissues in under the diaphragm also look fine. So we're

1:50

left here with this heart. Unfortunately. This

1:53

patient doesn't have any prior. So we don't have the ability to compare

1:56

has this change has this been the same

1:59

and so certainly a rapidly enlarging cardiac

2:02

silhouette would suggest

2:05

something like a pericardial effusion if this

2:08

is something that's been going on for a very long time and there's

2:11

been a workup. You may have Insight going on there.

2:14

From the lateral view we have additional information. So again,

2:17

we've talked about a nice opportunity to

2:20

look at the spine the vertical body Heights and Alignment, but you

2:23

can see really nicely that the posterior portion of

2:26

the heart which is the left ventricle down

2:29

in this region right here is actually protruding almost

2:32

touching the spine. So this is truly an enlarged cardiac

2:35

silhouette. We've also got filling in of the Retro sternal

2:39

clear space with this again, very large cardiac

2:42

silhouette. So it's not really clear where we

2:45

are in terms of pericardial effusion or intrinsic

2:48

myocardial dilitation. EKG would be

2:51

really helpful tool to understand that you can recommend that

2:54

clinically we do have a companion case that

2:57

actually looks at a CT which

3:00

will give us additional information.

3:02

So let's move now to the companion case.

3:05

And this is a companion case of a 56 year

3:08

old so slightly older where you can see that this patient

3:11

is intubated and the endotracheal tube

3:14

terminates at the level of the clavicles. There's also a

3:17

oral gastric tube which extends beyond the

3:20

field of view but is likely below the diaphragm and

3:23

at least somewhere in the stomach or projecting over the

3:26

stomach.

3:27

And again what we see here is a very large and globular shaped

3:30

cardiac silhouette. In addition. When we

3:33

look at the lung Fields unlike the other case here. We

3:36

have increased interstitial markings. There's kind of this period opacities.

3:39

We don't see a large right effusion.

3:43

But the left costophrenic angle as well as the left

3:46

Hemi diaphragm are completely obscured again.

3:49

We want to take a look at the ribs. Make sure we're not

3:52

missing anything.

3:53

Take a look at the clavicles the shoulders.

3:57

Under the diaphragm. And again, you may be left with the same

4:00

sort of question. You know, are we looking at an enlarged

4:03

structure that is pericardium or myocardium

4:06

and the CT will help

4:09

delineate what's going on there?

4:11

Now here on the CT. We have the opportunity to

4:14

see this follow-up patient. So again, this is the patient who is

4:17

intubated and has a oral gastric

4:20

tube. And what we begin to see is dense airspace consolidation.

4:24

throughout bilateral lungs effusion on

4:27

the right

4:29

But very importantly we see a very large

4:32

low attenuating.

4:35

area surrounding The myocardium

4:39

and this is a massive pericardial effusion.

4:42

So normally the pericardial fluid is about or less than

4:45

2 millimeters. And so if we want to take an area of maximal distance

4:48

we could easily measure.

4:52

you know all of this is

4:55

pericardium

4:56

And so eight centimeters there if

4:59

we look at on the right side.

5:04

somewhere in this region

5:06

you're looking at another six centimeters.

5:08

So this is a very large effusion. Even

5:11

if you take an area that's thinnest you're

5:15

already at almost two centimeters. When

5:18

really we're looking at two millimeters as the normal

5:21

cutoff.

5:22

So a couple of things to consider when you see an effusion

5:25

this large.

5:27

To think about the physiologic realities of

5:31

all of this fluid pressing up against

5:34

a beating heart and whether or

5:37

not you have tamponade one thing to look at and consider

5:40

is are the chambers filling and so here we do see the

5:43

left ventricle.

5:45

As well as right ventricles filling.

5:47

But we also notice that there is reflux of

5:50

contrast into the intra hepatic IVC.

5:55

That actually extends out into the hepatic veins

5:58

as well. And so this does suggest that

6:01

there is some degree of right heart dysfunction and

6:04

impedance to the forward flow.

6:08

another aspect of what we can take a look at is the caliber and

6:11

the size of

6:13

the main pulmonary artery which here measures

6:17

Four centimeters which is much larger than

6:20

we would expect. So again,

6:22

there is some degree of

6:25

evidence that shows us that this very large effusion is

6:28

causing physiologic tamponade.

6:31

So obviously we found a reason for this patients symptomology, but

6:34

we don't want to fall victim to satisfaction

6:37

of search. We want to make sure that we've cleared some

6:40

other things. So part of what we discussed was whether or

6:43

not The myocardium itself was dilated and you

6:46

can see through the pericardial effusion the size

6:49

of the heart itself is actually normal in size. But what we were seeing

6:52

was and in large pericardium, we also

6:55

want to take a look at the lungs and while the contrast shows us

6:58

that there are no filling defects. There's not any evidence of

7:01

pulmonary emboli. We do see bilateral airspace

7:04

consolidation and we want to

7:07

better understand what's happening there.

7:09

So let's take a look at the lung windows and just scroll

7:12

through and we see here some of this ground glass some

7:15

of this is focal and consolidated.

7:18

We do have a plural effusion. That's small here

7:21

on the right.

7:23

The Airways themselves are patent. We

7:26

talked about the endotrachal tube as well

7:29

as the oral gastric tube.

7:31

So in addition to having some airspace consolidation,

7:34

some of this could be related to aspiration. Although we

7:37

don't see a whole lot in the Airways except we do

7:40

see a little bit of frothiness along here. So this could certainly be

7:43

a patient with a massive aspiration or with pneumonia.

7:47

This patient has a large pericardial effusion.

7:51

So we want to make sure we report all these findings and I think kind of

7:54

the biggest thing here would be a pericardial effusion. That is so large that

7:57

it does cause and does have evidence of tamponade on

8:00

the coronal views again, really nicely

8:03

shows us that the heart size

8:06

itself is normal in caliber what

8:09

we do see the reflux of contrast really nicely down into the

8:12

intra-patic IVC into the hepatic veins

8:15

and you can see really nicely how large is pericardial

8:18

effusion is how extensive and posterior

8:21

it extends and that

8:24

there is dilatation of the main pulmonary

8:27

artery.

8:29

Again, we see really nicely on the coronal View.

8:32

the airspace consolidation

8:34

and we've talked about that before.

8:37

So here we've got multiple findings, but the main one that we're

8:40

using as an illustration here and as a follow-up is pericardial

8:43

effusion to be careful

8:46

again, as you're looking at this on x-ray to

8:49

be able to determine sometimes it's difficult. Are you

8:52

looking at Big dilated myocardium or

8:55

big fluid-filled pericardial space

8:58

pericardly effusion both can give you a big

9:01

heart.

9:02

one last thing to just remember as you're looking through this and

9:05

information that you want to use is

9:08

take an opportunity to measure the hounds field

9:11

units of the fluid here. So simple pericardial

9:14

fluids should be low in attenuation versus something

9:17

that's hemorrhagic or could be exudative filled

9:20

with protein or exudates or infection are

9:23

going to have a higher number so we can put

9:26

an Roi on this area and see

9:29

what it measures.

9:30

And here it's measuring.

9:32

Less than 16 and so this

9:35

would be certainly consistent with a very large but simple fluid

9:38

effusion.