SonoTip&Trick: “I can’t tell if it’s a pleural or pericardial effusion.” Really? well here’s a tip…

There was a case a few years back that got a lot of attention. 56 year old hypotensive and the providers could have sworn that he had a pericardial effusion, and thus tamponade because they saw the image below on their AP4 and PSL views. They called the cath lab and the cardiology fellow who also performed their echo thought the same and set it up for the patient to get a pericardial window as he was… well….”unstabley stable” – as one of my mentors would say.

AP4:

PSL:

Ok, so there is a HUGE effusion and the RV doesnt seem to be filling. I get it, totally. A sick patient and you see this, needing to act quickly, looks like a possible tamponade. But….then the EM resident did a RUQ and LUQ view just before transfer to the cath lab and saw:

RUQ:

LUQ:

So, as the above image states, there were 2 bilateral and large pleural effusions. This can definitely be seen around the heart. So how can you tell the difference between this and a pericardial effusion?

1. See if the effusion is anterior and posterior to the 4 chamber heart in subxiphoid view, to suggest that it is within the pericardium and not around it

2. On the parasternal long (PSL) view, look at the transverse (circular) descending aorta which is just deep to the heart. Anechoic fluid that travels posterior to the heart and coming to a point in front of the aorta (anterior to it) is a pericardial effusion. Anechoic fluid that travels to a point posterior to the aorta (deep to it) is a pleural effusion.

Pericardial effusion:

Pleural Effusion: