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

1. Hemopericardium
   1. Trauma
   2. Iatrogenic (misplaced central line)
   3. Bleeding diathesis
   4. Ventricular rupture (post-MI)
2. Non-hemopericardium
   1. Cancer
   2. Pericarditis
      1. Infectious
      2. Uremic (renal failure)
   3. HIV complications (infection, Kaposi sarcoma, lymphoma)
   4. SLE
   5. Post-radiation
   6. 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 pts)
  • Hypotension, muffled heart sounds, JVD

Diagnosis

1. Ultrasound
   1. Pericardial effusion, its important to note that in acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
   2. RV diastolic collapse, effusion, there is often RA systolic and diastolic collapse seen also
   3. 5% false negative (usually b/c pericardium is decompressing into L chest)
      1. Be suspicious if pt has a left-sided pulmonary effusion
   4. Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variablility of transvalvular flow, this is due to the phenomenon of ventricular interdependence
2. ECG
   1. Tachycardia (bradycardia is ominous finding)
   2. Normal or low voltage
   3. Electrical alternans, low voltage QRS
3. CXR
   1. Enlarged cardiac silhouette
4. Pulsus Paradoxus
   1. >10mmHg change in sys 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

1. Admit with cardiology/CT surgery consult

See Also

• Pericardiocentesis
• Thoracic Trauma
• Pericarditis
• Ultrasound: Cardiac

Source

Tintinalli