Pericardial effusion and tamponade

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Background

  • Always consider in patient with PEA
  • Always consider in patient with 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

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Clinical Features

  • 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

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

Pericardial Effusion.png

ECG

  • Can be normal
  • Tachycardia (bradycardia is ominous finding)
  • Electrical alternans
  • Low voltage
    • All limb lead QRS amplitudes <5 mm or I+II+III<15;[1]
    • OR All precordial QRS amplitudes <10 mm or V1+V2+V3<30

CXR

  • Enlarged cardiac silhouette

Pulsus Paradoxus

  • >10mmHg change in systolic BP on inspiration

Management

Hemorrhagic Tamponade

Non-hemorrhagic Tamponade

Disposition

  • Admit with cardiology/CT surgery consult

See Also

References

  1. Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.