| Snapshot |
| A 19-year-old man is stabbed in the left side of his chest. His blood pressure on presentation is 90/60 mmHg with a pulse of 130/min. On physical exam, he has muffled heart sounds and distended jugular veins. Upon inspiration, his blood pressure drops to 75/55 mmHg. His extremities are cool and clammy. He is immediately rushed to the operating room. |
| Introduction |
| Clinical definitionaccumulation of fluid in the pericardial sac that restricts ventricular fillingEpidemiologyrisk factorspericarditismalignancyuremiasystemic lupus erythematosusmalignancytuberculosispenetrating traumaEtiologypericardial effusionhemorrhage into pericardial saciatrogenicPathoanatomypericardiumthe pericardium is an elastic sac that can stretch to accommodate normal cardiac volume expansionhowever, if stretched beyond normal physiological expansion, the pericardium will stiffenPathogenesiscardiac tamponadeincreased pericardial pressure from the fluid accumulation causes compression of the cardiac chambersthis results in decreased cardiac output and blood pressurepulsus paradoxusinhalation increases venous return → expands the right ventriclein cardiac tamponade, the stiff pericardium will prevent the free wall from expandingthe only area for the right ventricle to expand is the interventricular septum, which will compress the left ventriclecompression of the left ventricle → decreased filling of the left heart → decreased blood pressure Associated conditionsruptured ascending aortic dissectionventricular free wall rupture from myocardial infarctionPrognosisin acute cases, cardiac tamponade can develop rapidlyin chronic cases, cardiac tamponade will develop gradually, as the pericardium can adjust slowly to the increased pressure over time |
| Presentation |
| Symptomschest painfatigabilityoften unresponsive to fluid resuscitationPhysical examBeck triadmuffled heart soundsjugular venous distention hypotensioncardiac↑ heart ratepericardial rub if the patient has an inflammatory pericarditispulsus paradoxus decrease of blood pressure > 10 mmHg during inhalation pulmonaryshortness of breathlung fields are typically clearextremitiescold and clammyperipheral cyanosis |
| Imaging |
| Echocardiography indicationsfor diagnosis of cardiac tamponademost accurate testfor all patientsfindingsdiastolic collapse of the right heartfluid in the pericardial spaceswinging of the heart within the effusionRadiography indicationfor all patientsviewschestfindingsenlarged cardiac silhouette seen only in subacute cardiac tamponadein acute cases, pericardium will not accomodate build up of > 200 cc of fluid, which is required to appear enlarged on radiograph |
| Studies |
| Electrocardiogram (ECG) indicationfor all patientsfindingslow voltageelectrical alternans variations in the height of the QRS complexfrom swinging of the heart in the chestRight heart catheterizationindicationtypically not performed as an initial testfindingequilibration of pressures in all 4 chambers during diastoleMaking the diagnosisbased on clinical presentation, ECG, echocardiogram, and chest radiography |
| Differential |
| Constrictive pericarditisdistinguishing factorsalso has pulsus paradoxus, but also presents withKussmaul signincrease (or absence of decline) in jugular venous pressure with inhalationpericardial knockTension pneumothoraxdistinguishing factorsdecreased or absent breath soundshyperresonant percussion |
| Treatment |
| Management approachall approaches focus on removal of the fluid in the pericardiumConservativeclose monitoring and volume expansionindicationcardiac tamponade without hemodynamic compromisemodalitiesserial echocardiographsintravenous bolus of fluidsProcedural percutaneous pericardiocentesisindicationfirst-line treatmentOperativesurgical drainageindicationspatients with coagulopathy or need for biopsypurulent pericarditistraumatic cardiac tamponadesurgical drainage with pericardial window placementindicationpatients with chronic pericardial effusionspatients who decompensate |
| Complications |
| Death |
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