Pericardial effusion and tamponade

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
  • 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
  • STEMI
  • Non-STEMI
  • Unstable angina
• Aortic Dissection
• Cardiac Tamponade
• Pulmonary Embolism
• Tension Pneumothorax
• Boerhhaave's Syndrome
• Coronary Artery Dissection

Emergent

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

Nonemergent

• Stable angina
• Asthma exacerbation
• Valvular Heart Disease
• Aortic Stenosis
• Mitral valve prolapse
• Hypertrophic cardiomyopathy
• Pneumonia
• Pleuritis
• Tumor
• Pneumomediastinum
• Esophageal Spasm
• Gastroesophageal Reflux Disease (GERD)
• Peptic Ulcer Disease
• Biliary Colic
• Muscle sprain
• Rib Fracture
• Arthritis
• Chostochondirits
• Spinal Root Compression
• Thoracic outlet syndrome
• Herpes Zoster / Postherpetic Neuralgia
• Psychologic / Somatic Chest Pain
• Hyperventilation
• Panic attack

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

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;
  • 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

• Can occur if ECG read as STEMI/NSTEMI and heparin started
• Pericardiocentesis
  • Temporizing measure until thoracotomy can be performed
• IVF to increase RV volume and maintain preload
• 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
• Cardiac ultrasound

References

Authors

Jordan Swartz, Ross Donaldson, Mustafa Ahmed, Kevin Lu, Neil Young, Daniel Eggeman, Abdus Salam Khan, Claire, Jesse Gentiluomo, Daniel Ostermayer, Marissa Camilon