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

Critical

• Acute Coronary Syndromes
• Aortic Dissection
• Cardiac Tamponade
• Pulmonary Embolism
• Tension Pneumothorax
• Boerhhaave's Syndrome
• Coronary Artery Dissection

Emergent

• Pericarditis
• Myocarditis
• Pneumothorax
• Mediastinitis
• Cholecystitis
• Pancreatitis

Nonemergent

• 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

1. Rib Fracture
2. Arthritis

• Tumor
• Chostochondirits
• Spinal Root Compression
• Thoracic Outlet Syndrome
• Herpes Zoster / Postherpetic Neuralgia
• Psychologic Chest Pain
• Hyperventilation
• Panic Attack

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 effusion
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

1. Hemorrhagic Tamponade
   1. Pericardiocentesis
      1. Temporizing measure until thoracotomy can be performed
   2. IVF to increase RV volume
   3. Meds
      1. Pressors (temporizing)
      2. Avoid preload reducing meds (nitrates, diuretics)
2. Non-hemorrhagic Tamponade
   1. Pericardiocentesis
   2. Dialysis for pt w/ known renal failure

Disposition

1. Admit with cardiology/CT surgery consult

See Also

• Pericardiocentesis
• Thoracic Trauma
• Pericarditis

Source

Tintinalli

Authors

Jordan Swartz, Ross Donaldson, Marissa Camilon