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
   3. HIV complications (infection, Kaposi sarcoma, lymphoma)
   4. Renal failure
   5. SLE
   6. Post-radiation
   7. Myxedema

DDx

1. Tension PTX
2. PE
3. Aortic dissection
4. SVC syndrome
5. Large pleural effusion/hemothorax
6. Constrictive pericarditis
7. Cardiogenic shock

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. RV collapse, effusion
   2. 5% false negative (usually b/c pericardium is decompressing into L chest)
      1. Be suspicious if pt has a left-sided pulmonary effussion
2. ECG
   1. Tachycardia (bradycardia is ominous finding)
   2. Normal or low voltage
   3. Electrical alternans
3. CXR
   1. Enlarged cardiac silhouette
4. Pulsus paradoxus
   1. >10mmHg change in sys BP on inspiration

Treatment

• Tamponade:
  • Pericardiocentesis
  • IVF to increase RV volume
  • Meds
    • Pressors (temporizing)
    • Avoid preload reducing meds (nitrates, diuretics)
• Effusion without tamponade:
  • Urgent dialysis for pt w/ known renal failure

Disposition

1. Admit with cardiology/CT surgery consult

See Also

• Pericardiocentesis
• Thoracic Trauma
• Pericarditis

Source

Tintinalli