EM@3AM – Cardiac Tamponade

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 55-year-old male presents to the emergency department for generalized malaise and weakness. The man notes the onset of his symptoms as 24 hours prior to arrival; associated with intermittent mid-sternal chest pain and shortness of breath. He denies diaphoresis, nausea, emesis, fevers, ill contacts, and a personal/familial history of cardiac disease and DVT/PE. Review of systems is remarkable for hospital discharge 3 days prior (cardiac ablation: a.fib).

Initial VS: BP 88/62, HR 110, T 98.9F Oral, RR 18, SpO2 98% on room air.

Examination is significant for JVD, muffled heart sounds, and peripheral edema.

What’s the next step in your evaluation and treatment?

Answer: Cardiac Tamponade^1-7

• Etiology: Arising secondary to conditions causing acute or chronic pericardial inflammation and subsequent pericardial effusion (HIV, SLE, TB, malignancy, severe hypothyroidism, uremia, etc.), or resulting from trauma or cardiac surgery.¹
• Presentation: Varies according to the size/rate of accumulation of the pericardial effusion:
  • Subacute/chronic:
    • Generalized malaise, ascites, edema secondary to decreased cardiac output.
    • Cough due to displacement or compression of bronchial structures.
    • Dyspnea on exertion as a result of decreased cardiac output.
    • Dysphagia as a result of esophageal compression.
  • Acute
    • Hemodynamic instability and/or cardiovascular collapse.
•  Evaluation:
  • Perform a thorough H&P:
    • VS abnormalities: persistent tachycardia (subacute/chronic)
    • HEENT: JVD
    • CV: muffled heart sounds, pericardial friction rub, peripheral edema
    • Abdomen: hepatomegaly (subacute/chronic)
  • Bedside echo^2,3 => Subxiphoid and apical four-chamber views allow for visualization of the pericardial sac and the right side of the heart (most affected by increasing external pressures from the filling pericardium).²
    • Signs indicating tamponade: pericardial effusion (an anechoic stripe of fluid between the parietal and visceral pericardium) accompanied by right atrial collapse during ventricular systole (first sign to appear³), right ventricular collapse during diastole, and a lack of respiratory variation upon examination of the inferior vena cava (IVC) (IVC diameter >2 cm with the absence of inspiratory collapse³).
  •  EKG^1,4 => low voltage QRS, tachycardia, electrical alternans, PR depression, non-specific ST-T wave changes
  • CXR^1,4 => increased cardiac silhouette as compared to previous (most commonly utilized to evaluate for alternative diagnoses, e.g. pulmonary edema or pneumonia).
  • CT or MRI may frequently preferred in the hemodynamically stable.¹
  • Pulsus paradoxus^1,4 => Sources offer differing definitions: > 10-12 mmHg variation in systolic pressure with respiration.
•  Treatment:
  • Address the ABCs:
    • Caution with mechanical ventilation: positive airway pressure increases intrathoracic pressure and reduces preload. Advised only for patients experiencing respiratory failure.¹  
    • Administer fluid resuscitation in the setting of hypovolemia.⁶
    • Evidence regarding the use of inotropes is lacking – consider milrinone or dobutamine (reduce elevated vascular resistance).¹
  • Perform emergent pericardiocentesis for the hemodynamically unstable. Echo/CT/fluoroscopy-guided pericardiocentesis for the hemodynamically stable.
    • Indications for surgical drainage: patients in whom intrapericardial bleeding is present (post-op pericardial tamponade, traumatic pericardial tamponade, pericardial tamponade with concomitant aortic dissection), or in the setting of clotted hemopericardium.¹
  • Evaluation and treatment of potential underlying etiologies as appropriate (laboratory studies, cultures, etc.).

• Pearls:
  • Beck’s triad (JVD, muffled heart sounds, hypotension), pulsus paradoxus, EKG changes, peripheral edema, and hepatomegaly are non-specific in the identification of subacute/chronic cardiac tamponade.⁵
  • Electrical alternans is present in less than 1/3 of patients with cardiac tamponade.¹
  • Pulsus paradoxus may occur in the setting of massive PE, hemorrhagic shock, or obstructive lung disease.¹
  • The use of electrocardiography during the performance of pericardiocentesis is no longer advised as attaching an electrode to the pericardiocentesis needle often provides misleading results.⁷

 References:

1. Mattu A, Martinez J. Pericarditis, Pericardial Tamponade, and Myocarditis. In Emergency Medicine Clinical Essentials, 2^nd ed. Philadelphia, Saunders. 2013.
2. Herndon M, Erickson C. American College of Emergency Medicine: “Ultrasound use in resuscitation.” Critical Decisions in Emergency Medicine. Available from: https://www.acep.org/uploadedFiles/ACEP/MeetingSites/SIM/Registration/Ultrasound%20Use%20in%20Resuscitation.pdf
3. Budhram G, Reardon R, Plummer D. Critical Care. In Ma & Mateer’s Emergency Ultrasound. 3^rd ed. New York, McGraw-Hill. 2014.
4. Jacob S, Sebastian J, Cherian P, Abraham A, John S. Pericardial effusion impending tamponade: a look beyond Beck’s triad. Am J Emerg Med. 2009; 23(2):216-219.
5. Eisenberg M, de Romeral L, Heindrenreich P, Schiller N, Evans G. The diagnosis of pericardial effusion and cardiac tamponade by 12-lead EKG. A technology assesment. Chest. 1996; 11-:318-324.
6. Hashim R, Frankel H, Tandon M, et al. Flud resuscitation-induced cardiac tamponade. Trauma. 2002; 53:1183.
7. Spodick D. Acute cardiac tamponade. N Engl J Med. 2003; 349:684-690.

For Additional Reading:

The Crashing Patient with Cardiac Tamponade: ED Management

The Crashing Patient with Cardiac Tamponade: ED Management