Pericardial Effusion/Tamponade, Emergency Medicine

Basics

Description

Pericardial effusion:
- Pericardial sac usually contains 15 " 40 cc of fluid
- Collection of additional fluid = effusion
Pericardial tamponade:
- Accumulation of pericardial fluid causes an elevation of pressure in the pericardial space, resulting in impairment of ventricular filling and decreased cardiac output.
- Depends on size and speed of fluid accumulation
- Increase of as little as 80 " 120 cc of fluid may lead to a rise in pericardial pressure.
- Up to 70% present in "early tamponade " and appear clinically stable
- Occurs in 2% of patients with penetrating chest trauma

Etiology

Medical causes:
- Pericarditis (20%):
  - 90% idiopathic or viral
  - Bacterial, fungal, parasitic, tuberculosis, HIV
- Malignancy (13%):
  - Lymphoma, leukemia, melanoma, breast, lung
  - Metastatic disease, primary malignancy, postradiation
- Postmyocardial infarction (8%):
  - Acute: 1 " 3 days after acute myocardial infarction (AMI)
  - Subacute (Dressler syndrome): Weeks to months after AMI
  - Incidence reduced with reperfusion therapy
- End-stage renal disease, uremia (6%)
- Autoimmune/collagen vascular disease (5%): Rheumatoid arthritis, systemic lupus erythematosus, scleroderma
- Rheumatic fever
- Radiation therapy
- Myxedema
- Congestive heart failure (CHF), valvular heart disease
- Drug toxicity (isoniazid, doxorubicin, procainamide, hydralazine, phenytoin)
- Idiopathic
Surgical causes:
- Penetrating chest trauma
- Thoracic aortic dissection
- Iatrogenic (cardiac catheterization, postcardiac surgery, central line placement)
- Blunt trauma rarely causes pericardial effusion.

Diagnosis

Signs and Symptoms

Becks triad = classic presentation of cardiac tamponade:
- Hypotension
- Muffled heart sounds
- Jugular venous distention
Dressler syndrome: Pericarditis seen several weeks after a myocardial infarction:
- Fever
- Chest pain
- Pericardial friction rub

History

Past medial history is key:
- History of malignancy?
- Recent viral illness?
- Connective tissue disorder?
- Recent MI?
History of the present illness:
- Most are asymptomatic.
- Pulmonary symptoms: Dyspnea, cough:
  - Dyspnea is the most common symptom seen in tamponade (87 " 88% sensitivity).
- Chest pain is the most common symptom:
  - Usually sharp, pleuritic, relieved by sitting forward
  - Can be referred to scapula
  - Can also be dull, aching, constrictive
- GI symptoms: Nausea or abdominal pain from hepatic and visceral congestion or dysphagia from esophageal compression
- Generalized symptoms: Fatigue, malaise

Physical Exam

Signs of shock or right heart failure:
- Tachycardia, hypotension
- Jugular venous distention (may be absent if the patient is also hypovolemic)
Pericardial friction rub (100% specific):
- High-pitched "scratchy " sound
- Best heard at left sternal border
- Increased by leaning forward
- Can be transient/intermittent
Pulsus paradoxus:
- Fall in systolic BP >10 mm Hg with inspiration
- When severe, this can manifest as lack of brachial or radial pulse during inspiration.
- Sensitive but not specific
Low-grade fever common; >38 °C is uncommon; if present, consider purulent pericarditis (can also result from autoimmune/connective tissue disease).
Lungs should be clear; if not, consider CHF or pneumonia.

Essential Workup

ECG
CXR
US:
- Echocardiography, including evaluation of aortic root
- Shock US: Include focused assessment with sonography in trauma, aorta, pleural effusion, and pneumothorax views to rule out other causes of hypotension

Diagnosis Tests & Interpretation

Lab

CBC
ESR, C-reactive protein:
- Usually elevated in pericarditis
Cardiac enzymes:
- Consider myocarditis if elevated
Electrolytes:
- BUN/creatinine in suspected uremic pericarditis
Coagulation profile:
- Especially in liver failure, anticoagulation, trauma
Blood cultures if an infectious source is suspected

Imaging

Chest radiograph:
- Cardiomegaly is 89% sensitive for tamponade.
- Can be normal even with effusion if developed quickly
Echocardiography:
- 97 " 100% sensitive, 90 " 97% specific
- Effusion: Can detect as little as 20 " 50 cc of pericardial blood/fluid:
  - Small effusions will only be seen posteriorly.
  - Anterior fat pad may mimic effusion; must also visualize posterior pericardial space for diagnosis of effusion.
- Tamponade:
  - Effusions large enough to cause tamponade should be circumferential.
  - Right atrial or ventricular bowing and eventual collapse
  - "Sniff " test: During inspiration, the inferior vena cava will not collapse in patients with tamponade.
Chest CT for detecting hemopericardium
Transesophageal echocardiography
MRI with gadolinium (for stable patients only)

Diagnostic Procedures/Surgery

ECG:
- Low voltage
- Electrical alternans: Alternating beat-to-beat variation of QRS amplitude (usually only seen with large effusions)
Pericardiocentesis and fluid analysis:
- Therapeutic for tamponade or large symptomatic effusion
- Diagnostic for bacterial effusion (to guide antibiotics) or malignant effusion (for cytology)
Central venous pressure (CVP) determination:
- CVP >15 cm H2O suggests tamponade, but may be normal in the hypovolemic patient.

Differential Diagnosis

Noncardiogenic shock:
- Hypovolemic, septic, anaphylactic, spinal
Other cardiac conditions:
- Myocardial infarction " common misdiagnosis!
- Pericardial constriction (due to pericardial fibrosis)
- CHF
Pulmonary conditions:
- Pulmonary embolus
- Tension pneumothorax
- Hemothorax
Other causes:
- Air embolism
- Aortic dissection
- Ruptured abdominal aortic aneurysm

Treatment

Pre-Hospital

2 large-bore IV lines
Start IV fluids.
Supplemental O2

Initial Stabilization/Therapy

Continue pre-hospital measures
Continuous cardiac monitoring
In tamponade:
- IV fluid resuscitation with normal saline or blood
- Pericardiocentesis for unstable patients to decompress the tamponade

Ed Treatment/Procedures

Medical causes of tamponade in patients who are unstable:
- Perform pericardiocentesis with placement of an indwelling catheter for continued drainage:
  - Site of drainage guided by maximum fluid collection
  - Subxiphoid: 2 cm below and 1 cm to the left of the xiphoid process, needle aimed at 30 " 45 ° angle toward the patients left shoulder
  - Left parasternal approach: 5th intercostal space just lateral to sternum, needle inserted perpendicular to the skin
  - Remove fluid as needed to improve clinical condition.
Traumatic pericardial tamponade:
- Consult trauma surgeon immediately.
- Definitive therapy is thoracotomy in the OR.
- If patient is deteriorating despite resuscitation, ED thoracotomy with pericardotomy is an option.
Bacterial pericardial effusion:
- Initiate antibiotic therapy to cover gram-negative and anaerobic organisms and Staphylococcus aureus.
- May ultimately require partial surgical resection of the pericardium
Uremic pericardial effusion:
- Arrange urgent dialysis.
Dressler syndrome and postirradiation pericardial effusion:
- Initiate aspirin
Aortic dissection:
- Immediate cardiothoracic surgical consultation for operative repair

Medication

Ibuprofen: 800 mg PO q8h
Indomethacin: 75 " 150 mg PO daily
Avoid NSAIDs in patients with CAD
Steroids:
- Only for refractory cases (more commonly associated with rebound when tapered)
- Prednisone: 0.2 " 0.5 mg/kg, continued for at least 1 mo, slowly tapered

Follow-Up

Disposition

Admission Criteria

ICU admission for acute, symptomatic pericardial effusion/tamponade
New pericardial effusion
Pericarditis with elevated troponin

Discharge Criteria

Known or incidentally found small pericardial effusion in asymptomatic stable patient
Pericarditis without evidence of tamponade in a young, healthy person whose pain is controlled with NSAIDs

Issues for Referral

Trauma surgery:
- Tamponade in setting of trauma: Will need to go to OR for thoracotomy (or from ED status post ED thoracotomy)
Cardiothoracic surgery:
- Tamponade/effusion in the setting of aortic dissection/other primary cardiac problem
- Patients requiring pericardial window
- Any patients who have had recent cardiac surgery
Cardiology/interventional cardiology:
- Dressler syndrome
- Recent percutaneous intervention
- Any patients who need pericardiocentesis

Followup Recommendations

Discharged patients need urgent primary care physician follow-up and repeat echo to evaluate for resolution of effusion.

Pearls and Pitfalls

ECG changes associated with pericarditis include diffuse ST-elevation with PR-depression and eventual T-wave inversion. Should be contrasted with ECG findings of localized ST-elevation with reciprocal ST-depression in AMI.
Relatively small effusions can cause tamponade if rapidly developing (conversely, large effusions can be relatively benign when they develop slowly).
Cardiac output can be fluid dependent in tamponade " start fluids early.
Use bedside US to look for pericardial effusion and other signs of tamponade in the setting of hypotension (including trauma).
ED thoracotomy should not be employed if there is no OR readily available.

Additional Reading

Bessen HA, Byyne R. Acute pericarditis and cardiac tamponade. In: Wolfson AB, ed. Harwood Nuss ' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:507 " 510.
Hoit BD. Pericardial disease and pericardial tamponade. Crit Care Med. 2007;35(8):S355 " S364.
Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases. Circulation. 2010;121:916 " 928.
Little WC, Freeman GL. Pericardial disease. Circulation. 2006;113:1622 " 1632.
Roy CL, Minor MA, Brookhart MA, et al. Does this patient with a pericardial effusion have cardiac tamponade? JAMA. 2007;297(16):1810 " 1818.
Shockley LW. Penetrating chest trauma. In: Wolfson AB, ed. Harwood Nuss ' Clinical Practice of Emergency Medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:990 " 999.

Codes

ICD9

423.3 Cardiac tamponade
423.9 Unspecified disease of pericardium

ICD10

I31.3 Pericardial effusion (noninflammatory)
I31.4 Cardiac tamponade

SNOMED

373945007 Pericardial effusion (disorder)
35304003 Cardiac tamponade (disorder)
405546008 Malignant pericardial effusion (disorder)

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