Inpatient / Cardiology
Pericardial Effusion and Tamponade
# Pericardial Effusion
# Cardiac Tamponade
Checklist:
-- ABCs: If unstable, STAT CT surgery page for pericardiocentesis once dx established
-- Chart Check: prior EKG, echos, recent procedures
-- Thorough HPI Intake: recent illnesses, h/o cancer (and cancer sxs) and treatment with radiation, h/o autoimmune disease (and rheum ROS)
-- Can't Miss: tamponade leadng to obstructive shock
-- Other Workup: CBC, coags, T+S, viral panel, EKG, echo, pericardial studies (see below)
-- Initial Treatment to Consider: pericardiocentesis is the only treatment to fix hemoynamic instability
Assessment:
-- History: *** timing, recent procedures, infections, previous MI, cancer screening, prev radiation, FHx autoimmune
-- Clinical: *** Beck Triad - hypotension, muffled heart signs, distended neck veins (JVP)
-- Exam: *** pulsus paradoxus (sens 82%, LR 5.9 >13; LR 3.3 if >10, LR 0.03 if <10), tachy (sens 77%), hypotension (sens 26%); friction rub (30% of cases) best heard end-expiration when leaning forward; Volume - JVP (sens 76%), Kussmaul Sign (sens 26%), crackles, edema, hepatomegaly
-- Data: *** EKG, Echo, CXR, troponin, creatinine, BUN
-- Etiology/DDx: *** Etiology: surgery, pericarditis, malignancy, radiation, uremia, autoimmune dx; hemopericardium from dissection, free wall rupture, trauma
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- Continuous telemetry
-- Serial pulsus paradoxus measurement
-- Pericardiocentesis: f/u *** cell count, total protein, LDH, cytology and tumor markers, gram stain and culture, AFB smear and culture, viral markers for coxsackie, HSV, CMV, EBV, HIV
Treatment
-- IV fluids: *** s/p ***
-- Inotropes: *** dobutamine
PDF template coming soon!
If You Remember Nothing Else
The classic Beck triad (hypotension, muffled heart sounds, distended neck veins) is not very sensitive - instead look for effusion on POCUS, pulses paradoxus, cardiomegaly on CXR. Pericardiocentesis should not be delayed if the patient is unstable - nothing else will fix the patient's hemodynamics. Tamponade can lead to PEA arrest. In terms of etiology, iatrogenic, infectious, malignant, and autoimmune are the most common.
Clinical Pearls
- Tamponade leads to equalization of diastolic pressures in all 4 chambers of the heart
- Tamponade physiology comes from increased intrapericardial pressure that causes compression of the heart, especially the right ventricle, leading to impaired cardiac filling and therefore reduced CO and hemodynamic insufficiency
- Ultimately, this leads to the equalization of diastolic pressures in all 4 chambers of the heart
- Tamponade can occur with small effusion, more based on the timing of accumulation and the ability of the body to adapt - the pericardium is stuff and the capacity of the pericardial space is limited but can stretch over a long period of time
- POCUS - best view is subxiphoid to assess for pericardial effusion - anechoic space >10mm indicated moderate effusion 500mL or greater; look for collapse of the right ventricle during systole, swinging motion of the heart
- Beck Triad - hypotension (26% sens), muffled heart signs (28% sens), distended neck veins (JVP) (76% sens)
- Pulses Paradoxus - decrease in BP amplitude by 10 during inspiration - more indicative of tamponade physiology than pericarditis; it is an exaggeration a normal decrease in SBP during inspiration (LR 3.3 if >10, LR 0.03 if <10)
- Pulsus paradoxus is easiest to see on a-line tracing - the difference in the height of the systolic waveform when expiring minus when inspiring; via BP cuff - the pressure when you only hear the Korotkoff sound when expiring minus pressure when you hear it throughout
- Differential for having pulsus paradoxus is COPD/asthma, massive PE, right-sided MI
- Dyspnea is the most sensitive clinical history finding for tamponade (~88%)
- Electrical alternans only has a sensitivity of 16-21% - presumed to be from swinging of the heart in the pericardial sac with heartbeats which doesn’t always happen - also note that there is usually a variation in amplitude with breaths
- Cardiomegaly (water bottle sign) on CXR is 89% sensitive for tamponade
- TTE - leftward septal shift with inspiration; diastolic collapse of cardiac chambers, worse on the right; IVC plump
- Pericardial window drains fluid either into the pleural space or the abdomen
- Tamponade can cause PEA but also a “pseudo-PEA” - see electrical activity AND heart is actually pumping (there is electrical capture) it just can’t generate enough CO to feel a palpable or find a dopplerable pulse
- You can use light’s criteria (like in pulmonary effusion) to help understand the etiology, though there are no established thresholds differentiating transudative vs exudative in pericardial effusions
- If malignant effusion, its most commonly from metastatic disease (lymphoma, leukemia, melanoma, breast, lung)
Trials and Literature
- Does This Patient with a Pericardial Effusion Have Cardiac Tamponade? Rational Clinical Exam
