Pericardial effusion and tamponade

Background

• Always consider in pt w/ PEA
• Always consider in pt w/ myocardial stab wound (80% result in tamponade)
  • GSW is less likely to result in tamponade b/c pericardial defect is larger
• Pathophysiology
  • Increased pericardial pressure > decreased RV filling > decreased CO

Etiology

• Hemopericardium
  • Trauma
  • Iatrogenic (misplaced central line)
  • Bleeding diathesis
  • Ventricular rupture (post-MI)
• Non-hemopericardium
  • Cancer - most commonly lung, breast
    • Melanoma has predilection for heart
    • May be related to radiation, infection, chemotherapy
  • Pericarditis
    • Infectious
    • Uremic (renal failure)
  • HIV complications (infection, Kaposi sarcoma, lymphoma)
  • SLE
  • Post-radiation
  • Myxedema

Differential Diagnosis

Chest pain

Critical

• Acute coronary syndromes (ACS)
  • STEMI
  • Non-STEMI
  • Unstable angina
• Aortic dissection
• Cardiac tamponade
• Coronary artery dissection
• Esophageal perforation (Boerhhaave's syndrome)
• Pulmonary embolism
• Tension pneumothorax

Emergent

• Cholecystitis
• Cocaine-associated chest pain
• Mediastinitis
• Myocardial rupture
• Myocarditis
• Pancreatitis
• Pericarditis
• Pneumothorax

Nonemergent

• Aortic stenosis
• Arthritis
• Asthma exacerbation
• Biliary colic
• Costochondritis
• Esophageal spasm
• Gastroesophageal reflux disease
• Herpes zoster / Postherpetic Neuralgia
• Hypertrophic cardiomyopathy
• Hyperventilation
• Mitral valve prolapse
• Panic attack
• Peptic ulcer disease
• Pleuritis
• Pneumomediastinum
• Pneumonia
• Rib fracture
• Stable angina
• Thoracic outlet syndrome
• Valvular heart disease
• Muscle sprain
• Psychologic / Somatic Chest Pain
• Spinal Root Compression
• Tumor

Clinical Features

• CP, SOB, fatigue
• CHF-type appearance
• Narrow pulse pressure
• Friction rub
• Beck's Triad (33% of patients)
  • Hypotension, muffled heart sounds, JVD

Diagnosis

1. Ultrasound
   • Pericardial effusion
     • In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
   • Diastolic collapse of the right atrium (in atrial diastole)
   • Diastolic collapse of the right ventricle
   • Plethoric IVC
   • Valvular pulsus parodoxus
     • Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow

1. ECG
   • Can be normal
   • Tachycardia (bradycardia is ominous finding)
   • Electrical alternans
   • Low voltage
     • All limb lead QRS amplitudes <5 mm;
     • OR All precordial QRS amp <10 mm
2. CXR
   • Enlarged cardiac silhouette
3. Pulsus Paradoxus
   • >10mmHg change in systolic BP on inspiration

Treatment

Hemorrhagic Tamponade

• Pericardiocentesis
  • Temporizing measure until thoracotomy can be performed
• IVF to increase RV volume
• Medications
  • Pressors (temporizing)
  • Avoid preload reducing medications (nitrates, diuretics)

Non-hemorrhagic Tamponade

• Pericardiocentesis
• Dialysis for patients with known renal failure

Disposition

• Admit with cardiology/CT surgery consult

See Also

• Pericardiocentesis
• Thoracic Trauma
• Pericarditis
• Ultrasound: Cardiac