Pericardial effusion and tamponade: Difference between revisions
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==Background==
==Background==
[[File:Body Cavities Frontal view labeled 2.jpg|thumb|The pericardial cavity in this image is labeled d and is part of the inferior mediastium. Here we can see its relation to the superior mediastinum a, the pleural cavities c, and the diaphragm e.]]
[[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.]]
[[File:2004 Heart Wall.jpg|thumb|Anatomy of the pericardium.]]
[[File:Pericardium anatomy.png|thumb|Anatomy of the pericardium.]]
*Always consider in patient with [[PEA]]
[[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.]]
*Always consider in patient with penetrating trauma anywhere in the cardiac box (80% result in tamponade)
*Pericardial effusion: abnormal accumulation of fluid in the pericardial space
**[[Gun shot wounds]] are less likely to result in tamponade because pericardial defect is larger
*Cardiac tamponade: hemodynamic compromise from pericardial fluid compressing the heart
**Right ventricle is the most commonly injured chamber of the heart due to its anatomic location<ref>Gunay C, et al. Surgical challenges for urgent approach in penetrating heart injuries. Heart Surg Forum. 2007;10(6):E473-E477. doi:10.1532/HSF98.20071098</ref>
**Rate of accumulation matters more than volume
*Pathophysiology
**Acute: as little as 100-150 mL can cause tamponade (e.g., trauma)
**Increased pericardial pressure > decreased RV filling > decreased cardiac output
**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)
**[[Coagulopathy|Bleeding diathesis]]
**[[Aortic dissection]] (type A with rupture into pericardium)
**[[Myocardial rupture|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 disorder]]s
**Idiopathic (up to 50% of large effusions)
**Post-radiation
**[[Myxedema]]


==Clinical Features==
==Clinical Features==
*[[Chest pain]], shortness of breath, cough, fatigue
*Chest pain, [[dyspnea]], cough, fatigue
*[[CHF]]-type appearance
*Tachycardia (most reliable sign; bradycardia is ominous/preterminal)
*Tachycardia
*Narrow pulse pressure
*Narrow pulse pressure
*Friction rub
*Friction rub (may be absent with large effusion)
*Pulsus paradoxus (dec in BP on inspiration)
*Pulsus paradoxus: >10 mmHg drop in systolic BP during inspiration
*Beck's Triad (33% of patients)
*Beck's triad (present in only ~33% of cases):
**[[Hypotension]]
**[[Hypotension]]
**Muffled heart sounds
**Muffled heart sounds
**JVD
**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]]
 
{{Chest pain DDX}}


==Evaluation==
==Evaluation==
===[[Pulsus Paradoxus]]===
===ECG===
*>10mmHg change in systolic BP on inspiration
*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<ref>Mattu A, Brady W. ''ECGs for the Emergency Physician 2''. BMJ Books. 2008.</ref>
**Precordial leads: all QRS <10 mm or V1+V2+V3 <30 mm
*PR depression (if associated pericarditis)
 
===CXR===
[[File:Massive pericardial effusion CXR.jpg|thumb|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


===[[CXR]]===
===Bedside Ultrasound (Test of Choice in ED)===
[[File:Massivepericarialeffusion.png|thumb|Massive pericardial effusion on chest x-ray]]
[[File:Pericardial effusion echo.jpg|thumb|Transthoracic echo of pericardial effusion showing "swinging heart"]]
*Enlarged cardiac silhouette
[[File:Pericardial effusion US.jpg|thumb|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<ref>Randazzo MR et al. ''Acad Emerg Med''. 2003. PMID 12957982</ref>


===[[ECG]]===
====Classic Findings of Tamponade====
[[File:Pericardial effusion with tamponade.png|thumb|Sinus tachycardia with low QRS voltage and electrical alternans]]
*Diastolic collapse of RA (earliest sign; >1/3 of cardiac cycle = significant)
*Often normal
*Diastolic collapse of RV (more specific)
*[[Tachycardia]] (bradycardia is ominous finding)
*Plethoric (non-collapsing) IVC (>2 cm, <50% collapse — sensitive but nonspecific)
*Electrical alternans
*Swinging heart within large effusion
*Low voltage
**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


===[[Cardiac ultrasound|Ultrasound]]===
====Advanced Echo Assessment====
[[File:Pericardial effusion with tamponade (cropped).gif|thumb|Transthoracic echo of pericardial effusion showing "swinging heart"]]
*M-mode: position through RV free wall on PLAX to identify diastolic collapse timing
[[File:PericardialeffusionUS.png|thumb|Pericardial effusion on ultrasound]]
*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>:
[[File:RV_Collapse_M_mode.JPG|thumbnail|Collapse M mode]]
**Mitral inflow variation >25% → likely tamponade
[[File:MV_inflow_variation.JPG|thumbnail|MV inflow variation]]
**Tricuspid inflow variation >40% → likely tamponade
*Pericardial effusion
**Helpful when RV is thickened (chronic pulmonary hypertension)
**In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
**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>Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982</ref>
*Classical ultrasound findings
**Diastolic collapse of the right atrium (in atrial diastole)
**Diastolic collapse of the right ventricle
**Plethoric IVC (highly sensitive but low specificity)<ref>What echocardiographic findings suggest a pericardial effusion is causing tamponade?  Am J Emerg Med. 2019 Feb;37(2):321-326. doi: 10.1016/j.ajem.2018.11.004. Epub 2018 Nov 17.</ref>
*Evaluating systolic vs. diastolic phases with M-mode
**Position in PSL view with M-mode line through where RV appears to collapse
**Allow M-mode line to pass through where the anterior MV hits the septum in diastole (much like evaluation of EPSS - see [[Formal echocardiography]])
**The period of time where the anterior leaflet of the mitral valve is open (and closest to the septum) is the period of diastole. Evaluate the anterior free wall of the right ventricle for collapse. The longer period of collapse during diastole is an indicator for advanced tamponade physiology
*Valvular pulsus paradoxus
**Obtain apical 4-chamber view, place doppler indicator in either MV or TV location
**Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow
**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>
***> 25%, likely tamponade physiology
***> 40% for tricuspid inflow variation
***Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients


==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===
*[[IVF]] bolus of 500-1000 ml (patient is pre-load dependent)
*Uremic tamponade: emergent [[dialysis]]
*[[Pericardiocentesis]] is definitive treatment
*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>
*Dialysis for patients with known [[renal failure]]
*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==
==External Links==
*[https://emedicine.medscape.com/article/152083-overview#showall Medscape - Cardiac Tamponade]
*[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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