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 Tamponade1-7

  • 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 echo2,3 => 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).
    •  EKG1,4 => low voltage QRS, tachycardia, electrical alternans, PR depression, non-specific ST-T wave changes
    • CXR1,4 => 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 paradoxus1,4 => 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, 2nd 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. 3rd 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

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