EM · Pericardial tamponade
Pericardial tamponade
Also known as Cardiac tamponade · Pericardial effusion with tamponade
Pericardial tamponade — the Beck triad of hypotension, a raised jugular venous pressure and muffled heart sounds, the preload-limited diastolic pathophysiology (why a nitrate or a diuretic collapses the output and a fluid bolus temporises), the bedside echocardiogram as the diagnostic test, the drainage decision (echo-guided pericardiocentesis for the medical tamponade, a resuscitative thoracotomy for the traumatic clotted tamponade, surgery for the aortic-dissection tamponade), and the pulsus paradoxus. ACEM-primary, globally tagged.
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Red flags
- Hypotension with a raised jugular venous pressure and clear lung fields is tamponade (or tension pneumothorax or a massive PE) until proven otherwise
- The bedside echocardiogram is the diagnostic test — do not wait for a chest radiograph or a CT in the unstable patient
- A fluid bolus temporises (the heart is preload-limited); a nitrate or a diuretic collapses the cardiac output and must be avoided
- A traumatic clotted tamponade is not drained by a needle — it needs a resuscitative thoracotomy
- Do not pericardially drain a tamponade of an aortic dissection unless the patient is arresting — the drainage drops the tamponade pressure and re-bleeds; the answer is surgery
Meet the patient
A 62-year-old woman with metastatic lung cancer has five days of progressive dyspnoea, orthopnoea, and dizziness. She is diaphoretic, breathless, unable to lie flat, HR 128, BP 86 over 58 with a pulsus paradoxus of 18 mmHg, the JVP distended to the angle of the jaw, the heart sounds muffled, the lung fields clear, the peripheries cool. The bedside echo shows a large circumferential effusion with right-atrial collapse in late diastole, a plethoric fixed IVC, and a swinging heart. There is no time for a chest radiograph or a CT — the picture is complete, and the next action is a pericardiocentesis.[1]
The two questions that govern every tamponade are the two the Fellowship candidate must hold: is the heart compressed, and what is the cause? (the echo answers the first, the history answers the second) and which drainage does the cause demand? — a needle for the medical effusion, a thoracotomy for the traumatic clot, surgery for the dissection. Hold those two and the rest of the topic slots into place.[1]
References12ShowHide
- [1]Charron P, Adler Y. 'Ten Commandments' of 2015 ESC Guidelines for diagnosis and management of pericardial diseases Eur Heart J, 2015.PMID 26866075
- [2]Marchetta M, Adamo L, Bonaventura A, et al. ABCDE of complex pericarditis cases Heart, 2026.PMID 42045051
- [3]Sagristà-Sauleda J, Angel J, Sambola A, et al. Low-pressure cardiac tamponade: clinical and hemodynamic profile Circulation, 2006.PMID 16923755
- [4]Tsang TS, Freeman WK, Barnes ME, et al. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience J Am Coll Cardiol, 1998.PMID 9809946
- [5]Drummond JB, Seward JB, Tsang TS, et al. Outpatient two-dimensional echocardiography-guided pericardiocentesis J Am Soc Echocardiogr, 1998.PMID 9619614
- [6]Imazio M, Brucato A, Ferrazzi P, et al. Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation: the COPPS-2 randomized clinical trial JAMA, 2014.PMID 25172965
- [7]Imazio M, Lazaros G, Valenti A, et al. Outcomes of idiopathic chronic large pericardial effusion Heart, 2019.PMID 30274986
- [8]Maggiolini S, Gentile G, Farina A, et al. Safety, Efficacy, and Complications of Pericardiocentesis by Real-Time Echo-Monitored Procedure Am J Cardiol, 2016.PMID 26956635
- [9]Maggiolini S, De Carlini CC, Imazio M. Evolution of the pericardiocentesis technique J Cardiovasc Med (Hagerstown), 2018.PMID 29553993
- [10]Khalid N, Chhabra L, Spodick DH. Response to Role of a 12-Lead Electrocardiogram in the Diagnosis of Cardiac Tamponade as Diagnosed by Transthoracic Echocardiography in Patients With Malignant Pericardial Effusion Clin Cardiol, 2015.PMID 26216007
- [11]Avondo S, Andreis A, Casula M, Imazio M. Update on diagnosis and management of neoplastic pericardial disease Expert Rev Cardiovasc Ther, 2020.PMID 32797759
- [12]Bizzi E, Picchi C, Mastrangelo G, et al. Recent advances in pericarditis Eur J Intern Med, 2022.PMID 34556390