Cardiac Tamponade / Pericardial Effusion – Quick Consult
Last Updated / Reviewed: June 2022

Key History
Key Physical Exam
Risk Factors for Cardiac Tamponade
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment

Key History

  • Chest pain, discomfort or fullness
  • Dyspnea on exertion
  • Intolerance to activity
  • Trauma – penetrating cardiac injury
  • History of:
    • MI
    • SLE, RA
    • End stage renal disease
    • Radiation
    • Malignancy
    • Cardiac surgery
    • Pericarditis
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Key Physical Exam

  • Clear lungs
  • Cyanosis
  • Hypotension, distended neck veins, distant heart sounds – Beck’s Triad
  • Kussmaul’s sign – rise in jugular venous pressure on inspiration
  • Narrow pulse pressure
  • Precordium with decreased or absent palpable cardiac heave or thrust
  • Pulsus paradoxus*
  • RUQ tenderness secondary to hepatic engorgement
*Pulsus paradoxus: The first sphygmomanometer reading is recorded at the point when heartbeat is audible during expiration and disappears with inspiration. The second reading is taken when each beat is audible during the respiratory cycle. A difference of more than 10 mm Hg defines pulsus paradoxus.

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Risk Factors for Cardiac Tamponade

  • Chest trauma
  • HIV
  • Hospitalized patients with systemic illness
  • Hypothyroidism
  • Iatrogenic – central line placement, pacemaker insertion, cardiac catheterization, pericardiotomy
  • Malignancy – breast, lung, lymphoma, leukemia
  • Post Myocardial infarction – Dressler’s syndrome
  • Rheumatoid Arthritis
  • Systemic Lupus Erythematosus
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Differential Diagnosis

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Diagnostic Testing

Text / literature information and recommendations include:

  • Labs:
    • CBC – rule out anemia
    • Cardiac biomarkers CKMB and Troponin r/o MI and myocardial injury
    • ESR, ANA, Rheumatoid factor
    • BUN/creatinine
    • BNP as clinically indicated
  • ECG
    • May show: sinus tachycardia, PR depression, low voltage QRS, or electrical alternans (beat to beat alterations in the QRS complex amplitude - is seen rarely)
  • Imaging
    • Chest radiograph may show an enlarged cardiac silhouette with clear lung fields (only with large fluid accumulation); the cardiac silhouette may be normal early in course
  • Ultrasound
    • Rapid bedside ultrasound exam – FAST (Focused Assessment with Sonography in Trauma)

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Clinical Risk and Safety Pearls

  • FAST exam at bedside for ED diagnosis of tamponade
  • Avoid preload reducing medications – nitrates, diuretics
  • Pericardiocentesis if cardiovascular collapse is imminent
  • Tamponade is most common in patients with malignant pericarditis.
  • Penetrating cardiac injuries may cause tamponade.
  • Hypovolemic patients with tamponade may not have elevated central venous pressure.
  • Beck’s triad may not be clinically apparent.
  • Large effusions tend to be chronic.
  • Tamponade is more likely with acutely occurring small effusions.

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Treatment

Common text / literature recommendations include:

  • ABC’s
  • IV fluids
  • Oxygen
  • Cardiac monitor
  • Vasopressors
  • Pericardiocentesis

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  1. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2015;36(42):2921-2964.
  2. Appleton C, Gillam L, Koulogiannis K. Cardiac tamponade. Cardiol Clin.2017;35(4):525-537.
  3. Hoit BD. Pericardial effusion and cardiac tamponade in the new millenium.Curr Cardiol Rep. 2017;19(7):57.
  4. Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr. 2013; 26:965.
  5. Kolski BC, Kakimoto W, Levin DL, Blanchard DG. Echocardiographic assessment of the accuracy of computed tomography in the diagnosis of hemodynamically significant pericardial effusions. J Am Soc Echocardiogr. 2008; 21:377.
  6. Restrepo, CS, Lemos, DF, Lemos, JA, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics 2007; 27:1595.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.
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