Pericardial effusion and tamponade: Difference between revisions
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==Background==
==Background==
*Always consider in patient with PEA
[[File:Pericardial anatomy diagram.png|thumb|(d) Pericardial cavity, part of the inferior mediastinum, in relation to (a) superior mediastinum; (c) pleural cavities; and (e) diaphragm.]]
*Always consider in patient with penetrating trauma anywhere in the cardiac box (80% result in tamponade)
[[File:Pericardium anatomy.png|thumb|Anatomy of the pericardium.]]
**Gun shot wounds are less likely to result in tamponade because pericardial defect is larger
[[File:Pericardial pressure volume curve.png|thumb|Pericardial pressure-volume relationships. Rapid accumulation (left curve) causes tamponade with small volumes; slow accumulation (right curve) allows pericardial stretching.]]
*Pathophysiology
*Pericardial effusion: abnormal accumulation of fluid in the pericardial space
**Increased pericardial pressure > decreased RV filling > decreased cardiac output
*Cardiac tamponade: hemodynamic compromise from pericardial fluid compressing the heart
**Rate of accumulation matters more than volume
**Acute: as little as 100-150 mL can cause tamponade (e.g., trauma)
**Chronic: up to 1-2 L may accumulate before tamponade (e.g., malignancy, uremia)
*Pathophysiology: increased pericardial pressure → decreased RV filling → decreased cardiac output
*Always consider in [[PEA]]
*Always consider in penetrating thoracic trauma within the cardiac box (80% result in tamponade)
**Gunshot wounds less likely to cause tamponade (larger pericardial defect allows decompression)
**RV is most commonly injured chamber due to anterior position


===Etiology===
===Etiology===
*Hemopericardium
*Hemopericardium:
**Trauma
**[[Trauma]] (penetrating or blunt), iatrogenic (central line, pacemaker, post-cardiac surgery)
**Iatrogenic (misplaced [[central line]])
**Ventricular free wall rupture (post-[[MI]], typically day 3-5)
**Bleeding diathesis
**[[Aortic dissection]] (type A with rupture into pericardium)
**Ventricular rupture (post-MI)
**Bleeding diathesis / anticoagulation
*Non-hemopericardium
*Non-hemorrhagic:
**Cancer - most commonly lung, breast, prostate, or hematologic
**Malignancy (most common cause of large effusions): lung, breast, lymphoma, melanoma
***[[Melanoma]] has predilection for heart
***Melanoma has particular predilection for cardiac metastasis
***May be related to radiation, infection, chemotherapy
**[[Pericarditis]] (viral, bacterial, tuberculous)
**[[Pericarditis]]
**Uremia ([[renal failure]])
***Infectious
**[[HIV]] (infection, Kaposi sarcoma, lymphoma)
***Uremic ([[renal failure]])
**Autoimmune ([[SLE]], [[rheumatoid arthritis]], scleroderma)
**[[HIV]] complications (infection, [[Kaposi sarcoma]], lymphoma)
**Post-radiation, [[hypothyroidism]]/myxedema
**[[SLE]] and other autoimmune or connective tissue disorders
**Idiopathic (up to 50% of large effusions)
**Post-radiation
 
**[[Myxedema]]
==Clinical Features==
*Chest pain, [[dyspnea]], cough, fatigue
*Tachycardia (most reliable sign; bradycardia is ominous/preterminal)
*Narrow pulse pressure
*Friction rub (may be absent with large effusion)
*Pulsus paradoxus: >10 mmHg drop in systolic BP during inspiration
*Beck's triad (present in only ~33% of cases):
**[[Hypotension]]
**Muffled heart sounds
**JVD (elevated CVP)
*Kussmaul sign: paradoxical rise in JVP with inspiration
*[[Hepatomegaly]], peripheral edema (if chronic)
*May present as [[PEA arrest]] or [[cardiogenic shock]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Chest Pain DDX}}
*[[Tension pneumothorax]] (absent breath sounds, tracheal deviation)
*Massive [[pulmonary embolism]]
*Acute [[MI]] / [[cardiogenic shock]]
*[[Constrictive pericarditis]]
*Acute [[heart failure]]
*[[Aortic dissection]]


==Clinical Features==
{{Chest pain DDX}}
*[[Chest pain]], shortness of breath, cough, fatigue
*[[CHF]]-type appearance
*Narrow pulse pressure
*Friction rub
*Pulsus paradoxus (dec in BP on inspiration)
*Beck's Triad (33% of patients)
**Hypotension, muffled heart sounds, JVD


==Evaluation==
==Evaluation==
===[[Cardiac ultrasound|Ultrasound]]===
===ECG===
[[File:Pericardial effusion with tamponade (cropped).gif|thumb|Transthoracic echo of pericardial effusion showing "swinging heart"]]
*Sinus tachycardia (most common finding)
*Pericardial effusion
*Electrical alternans (pathognomonic but insensitive — alternating QRS amplitude)
**In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
*Low voltage:
**Differentiate pericardial effusion from pleural effusion using the parasternal long axis view. Pericardial effusions will have an anechoic stripe between the left atrium and descending thoracic aorta. In a pleural effusion, the stripe will be seen behind the descending thoracic aorta.<ref>
**Limb leads: all QRS <5 mm or I+II+III <15 mm<ref>Mattu A, Brady W. ''ECGs for the Emergency Physician 2''. BMJ Books. 2008.</ref>
Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982</ref>
**Precordial leads: all QRS <10 mm or V1+V2+V3 <30 mm
*Classical ultrasound findings
*PR depression (if associated pericarditis)
**Diastolic collapse of the right atrium (in atrial diastole)
 
**Diastolic collapse of the right ventricle
===CXR===
**Plethoric IVC
[[File:Massive pericardial effusion CXR.jpg|thumb|Massive pericardial effusion on chest x-ray]]
*Evaluating systolic vs. diastolic phases with M-mode
*Enlarged cardiac silhouette (water bottle sign)
**Position in PSL view with M-mode line through where RV appears to collapse
*May be normal with small or acute effusions
**Allow M-mode line to pass through where the anterior MV hits the septum in diastole (much like evaluation of EPSS - see [[Formal echocardiography]])
*Not sensitive for early detection
[[File:RV_Collapse_M_mode.JPG|thumbnail]]
 
*Valvular pulsus parodoxus
===Pulsus Paradoxus===
**Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow
*>10 mmHg decrease in systolic BP during inspiration
**MV inflow respiratory variation, difference from highest velocity to lowest, as a percentage of highest velocity<ref>Rajagopalan N, Garcia MJ, Rodriguez L, Murray RD, Apperson-Hansen C, Stugaard M, Thomas JD, and Klein AL. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol. 2001 Jan 1;87(1):86-94.</ref>
*Measure with manual sphygmomanometer (inflate above systolic, slowly deflate noting first Korotkoff sounds in expiration vs inspiration)
***> 25%, likely tamponade physiology
*False negatives: [[aortic regurgitation]], [[ASD]], severe [[hypotension]], positive-pressure ventilation
***> 40% for tricuspid inflow variation
***Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients
[[File:MV_inflow_variation.JPG|thumbnail]]


===[[ECG]]===
===Bedside Ultrasound (Test of Choice in ED)===
[[File:Pericardial effusion with tamponade.png|thumb|Sinus tachycardia with low QRS voltage and electrical alternans]]
[[File:Pericardial effusion echo.jpg|thumb|Transthoracic echo of pericardial effusion showing "swinging heart"]]
*Often normal
[[File:Pericardial effusion US.jpg|thumb|Pericardial effusion on ultrasound]]
*Tachycardia (bradycardia is ominous finding)
*POCUS is the fastest and most reliable bedside diagnostic tool
*Electrical alternans
*Key views: subxiphoid (most sensitive), parasternal long axis (PLAX), apical 4-chamber
*Low voltage
*Distinguish from [[pleural effusion]] on PLAX: pericardial effusion tracks anterior to descending aorta; pleural effusion tracks posterior<ref>Randazzo MR et al. ''Acad Emerg Med''. 2003. PMID 12957982</ref>
**All limb lead QRS amplitudes <5 mm or I+II+III<15;<ref>Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.</ref>
**'''OR''' All precordial QRS amplitudes <10 mm or V1+V2+V3<30


===[[CXR]]===
====Classic Findings of Tamponade====
[[File:Massivepericarialeffusion.png|thumb|Massive pericardial effusion on chest x-ray]]
*Diastolic collapse of RA (earliest sign; >1/3 of cardiac cycle = significant)
*Enlarged cardiac silhouette
*Diastolic collapse of RV (more specific)
*Plethoric (non-collapsing) IVC (>2 cm, <50% collapse — sensitive but nonspecific)
*Swinging heart within large effusion


===[[Pulsus Paradoxus]]===
====Advanced Echo Assessment====
*>10mmHg change in systolic BP on inspiration
*M-mode: position through RV free wall on PLAX to identify diastolic collapse timing
*Doppler — valvular pulsus paradoxus<ref>Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684-690. PMID 12917306</ref><ref>Rajagopalan N, et al. Comparison of new Doppler echocardiographic methods. ''Am J Cardiol''. 2001;87(1):86-94. PMID 11137840</ref>:
**Mitral inflow variation >25% → likely tamponade
**Tricuspid inflow variation >40% → likely tamponade
**Helpful when RV is thickened (chronic pulmonary hypertension)


==Management==
==Management==
===Hemorrhagic Tamponade===
===Immediate Stabilization===
*Can occur if ECG read as STEMI/NSTEMI and heparin started
*IV fluid bolus 500-1000 mL NS (patient is preload-dependent)
*[[Pericardiocentesis]]
*Avoid preload-reducing medications: nitroglycerin, diuretics, morphine
**Temporizing measure until [[thoracotomy]] can be performed
*Avoid positive-pressure ventilation if possible (reduces preload further)
*[[IVF]] to increase RV volume and maintain preload
*Vasopressors as temporizing bridge (norepinephrine preferred)
*Medications
*Position patient upright or leaning forward if tolerated
**[[Pressors]] (temporizing)
 
**Avoid preload reducing medications ([[nitroglycerin]], [[diuretics]])
===Pericardiocentesis (Definitive for Non-hemorrhagic Tamponade)===
*Indications: hemodynamic compromise, suspected purulent pericarditis
*Ultrasound-guided approach preferred (reduces complications)
*Subxiphoid approach:
**Insert needle 1-2 cm inferior to left xiphosternal junction, aimed toward left shoulder
**Advance at 30-45° angle under US guidance
**As little as 30-50 mL removal can dramatically improve hemodynamics
*Send fluid for: cell count, protein, LDH, glucose, cytology, gram stain/culture, AFB
*Complication rate <2% with US guidance (vs ~20% blind)
 
===Traumatic Tamponade===
*Pericardiocentesis is a temporizing measure only — definitive treatment is thoracotomy
*Hemorrhagic tamponade will reaccumulate
*IV fluid resuscitation and emergent surgical consultation
*Can occur if ECG read as STEMI and heparin started inadvertently


===Non-hemorrhagic Tamponade===
===Specific Etiologies===
*[[Pericardiocentesis]]
*Uremic tamponade: emergent [[dialysis]]
*Dialysis for patients with known [[renal failure]]
*Malignant effusion: pericardiocentesis + consider pericardial window for recurrent effusions<ref>Adler Y, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964. PMID 26320112</ref>
*Post-MI free wall rupture: emergent cardiac surgery


==Disposition==
==Disposition==
*To OR if traumatic and hemodynamically unstable
*Unstable traumatic tamponade: emergent OR for thoracotomy
*Admit with cardiology/CT surgery consult
*All patients with tamponade physiology: ICU admission
*Large effusion without tamponade: admit with cardiology consultation
*Small effusion, stable, known etiology: may be managed as outpatient with close follow-up
*Consult: cardiology and/or CT surgery


==See Also==
==See Also==
*[[Pericardiocentesis]]
*[[Pericardiocentesis]]
*[[Thoracic Trauma]]
*[[Thoracic trauma]]
*[[Pericarditis]]
*[[Pericarditis]]
*[[Cardiac ultrasound]]
*[[Cardiac ultrasound]]
*[[PEA]]
==External Links==
*[https://emedicine.medscape.com/article/152083-overview Medscape - Cardiac Tamponade]


==References==
==References==
<references/>
<references/>
*Adler Y, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. ''Eur Heart J''. 2015;36(42):2921-2964. PMID 26320112
*Spodick DH. Acute cardiac tamponade. ''N Engl J Med''. 2003;349(7):684-690. PMID 12917306
*Ristic AD, et al. Triage strategy for urgent management of cardiac tamponade: a position statement of the ESC. ''Eur Heart J''. 2014;35(34):2279-2284. PMID 25002085


[[Category:Cardiology]]
[[Category:Cardiology]]

Latest revision as of 10:26, 22 March 2026

Background

File:Pericardial anatomy diagram.png
(d) Pericardial cavity, part of the inferior mediastinum, in relation to (a) superior mediastinum; (c) pleural cavities; and (e) diaphragm.
File:Pericardium anatomy.png
Anatomy of the pericardium.
File:Pericardial pressure volume curve.png
Pericardial pressure-volume relationships. Rapid accumulation (left curve) causes tamponade with small volumes; slow accumulation (right curve) allows pericardial stretching.
  • Pericardial effusion: abnormal accumulation of fluid in the pericardial space
  • Cardiac tamponade: hemodynamic compromise from pericardial fluid compressing the heart
    • Rate of accumulation matters more than volume
    • Acute: as little as 100-150 mL can cause tamponade (e.g., trauma)
    • Chronic: up to 1-2 L may accumulate before tamponade (e.g., malignancy, uremia)
  • Pathophysiology: increased pericardial pressure → decreased RV filling → decreased cardiac output
  • Always consider in PEA
  • Always consider in penetrating thoracic trauma within the cardiac box (80% result in tamponade)
    • Gunshot wounds less likely to cause tamponade (larger pericardial defect allows decompression)
    • RV is most commonly injured chamber due to anterior position

Etiology

  • Hemopericardium:
    • Trauma (penetrating or blunt), iatrogenic (central line, pacemaker, post-cardiac surgery)
    • Ventricular free wall rupture (post-MI, typically day 3-5)
    • Aortic dissection (type A with rupture into pericardium)
    • Bleeding diathesis / anticoagulation
  • Non-hemorrhagic:
    • Malignancy (most common cause of large effusions): lung, breast, lymphoma, melanoma
      • Melanoma has particular predilection for cardiac metastasis
    • Pericarditis (viral, bacterial, tuberculous)
    • Uremia (renal failure)
    • HIV (infection, Kaposi sarcoma, lymphoma)
    • Autoimmune (SLE, rheumatoid arthritis, scleroderma)
    • Post-radiation, hypothyroidism/myxedema
    • Idiopathic (up to 50% of large effusions)

Clinical Features

  • Chest pain, dyspnea, cough, fatigue
  • Tachycardia (most reliable sign; bradycardia is ominous/preterminal)
  • Narrow pulse pressure
  • Friction rub (may be absent with large effusion)
  • Pulsus paradoxus: >10 mmHg drop in systolic BP during inspiration
  • Beck's triad (present in only ~33% of cases):
  • Kussmaul sign: paradoxical rise in JVP with inspiration
  • Hepatomegaly, peripheral edema (if chronic)
  • May present as PEA arrest or cardiogenic shock

Differential Diagnosis

Template:Chest pain DDX

Evaluation

ECG

  • Sinus tachycardia (most common finding)
  • Electrical alternans (pathognomonic but insensitive — alternating QRS amplitude)
  • Low voltage:
    • Limb leads: all QRS <5 mm or I+II+III <15 mm[1]
    • Precordial leads: all QRS <10 mm or V1+V2+V3 <30 mm
  • PR depression (if associated pericarditis)

CXR

File:Massive pericardial effusion CXR.jpg
Massive pericardial effusion on chest x-ray
  • Enlarged cardiac silhouette (water bottle sign)
  • May be normal with small or acute effusions
  • Not sensitive for early detection

Pulsus Paradoxus

  • >10 mmHg decrease in systolic BP during inspiration
  • Measure with manual sphygmomanometer (inflate above systolic, slowly deflate noting first Korotkoff sounds in expiration vs inspiration)
  • False negatives: aortic regurgitation, ASD, severe hypotension, positive-pressure ventilation

Bedside Ultrasound (Test of Choice in ED)

File:Pericardial effusion echo.jpg
Transthoracic echo of pericardial effusion showing "swinging heart"
File:Pericardial effusion US.jpg
Pericardial effusion on ultrasound
  • POCUS is the fastest and most reliable bedside diagnostic tool
  • Key views: subxiphoid (most sensitive), parasternal long axis (PLAX), apical 4-chamber
  • Distinguish from pleural effusion on PLAX: pericardial effusion tracks anterior to descending aorta; pleural effusion tracks posterior[2]

Classic Findings of Tamponade

  • Diastolic collapse of RA (earliest sign; >1/3 of cardiac cycle = significant)
  • Diastolic collapse of RV (more specific)
  • Plethoric (non-collapsing) IVC (>2 cm, <50% collapse — sensitive but nonspecific)
  • Swinging heart within large effusion

Advanced Echo Assessment

  • M-mode: position through RV free wall on PLAX to identify diastolic collapse timing
  • Doppler — valvular pulsus paradoxus[3][4]:
    • Mitral inflow variation >25% → likely tamponade
    • Tricuspid inflow variation >40% → likely tamponade
    • Helpful when RV is thickened (chronic pulmonary hypertension)

Management

Immediate Stabilization

  • IV fluid bolus 500-1000 mL NS (patient is preload-dependent)
  • Avoid preload-reducing medications: nitroglycerin, diuretics, morphine
  • Avoid positive-pressure ventilation if possible (reduces preload further)
  • Vasopressors as temporizing bridge (norepinephrine preferred)
  • Position patient upright or leaning forward if tolerated

Pericardiocentesis (Definitive for Non-hemorrhagic Tamponade)

  • Indications: hemodynamic compromise, suspected purulent pericarditis
  • Ultrasound-guided approach preferred (reduces complications)
  • Subxiphoid approach:
    • Insert needle 1-2 cm inferior to left xiphosternal junction, aimed toward left shoulder
    • Advance at 30-45° angle under US guidance
    • As little as 30-50 mL removal can dramatically improve hemodynamics
  • Send fluid for: cell count, protein, LDH, glucose, cytology, gram stain/culture, AFB
  • Complication rate <2% with US guidance (vs ~20% blind)

Traumatic Tamponade

  • Pericardiocentesis is a temporizing measure only — definitive treatment is thoracotomy
  • Hemorrhagic tamponade will reaccumulate
  • IV fluid resuscitation and emergent surgical consultation
  • Can occur if ECG read as STEMI and heparin started inadvertently

Specific Etiologies

  • Uremic tamponade: emergent dialysis
  • Malignant effusion: pericardiocentesis + consider pericardial window for recurrent effusions[5]
  • Post-MI free wall rupture: emergent cardiac surgery

Disposition

  • Unstable traumatic tamponade: emergent OR for thoracotomy
  • All patients with tamponade physiology: ICU admission
  • Large effusion without tamponade: admit with cardiology consultation
  • Small effusion, stable, known etiology: may be managed as outpatient with close follow-up
  • Consult: cardiology and/or CT surgery

See Also

External Links

References

  1. ↑ Mattu A, Brady W. ECGs for the Emergency Physician 2. BMJ Books. 2008.
  2. ↑ Randazzo MR et al. Acad Emerg Med. 2003. PMID 12957982
  3. ↑ Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684-690. PMID 12917306
  4. ↑ Rajagopalan N, et al. Comparison of new Doppler echocardiographic methods. Am J Cardiol. 2001;87(1):86-94. PMID 11137840
  5. ↑ Adler Y, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964. PMID 26320112
  • Adler Y, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964. PMID 26320112
  • Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684-690. PMID 12917306
  • Ristic AD, et al. Triage strategy for urgent management of cardiac tamponade: a position statement of the ESC. Eur Heart J. 2014;35(34):2279-2284. PMID 25002085
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