Key History

Key Physical Exam

Risk Factors for Cardiac Tamponade

Differential Diagnosis

Diagnostic Testing

Text / literature information and recommendations include:

• Echocardiography: This is the primary imaging modality for diagnosing cardiac tamponade. It can identify pericardial effusion, right atrial and right ventricular diastolic collapse, and a plethoric inferior vena cava that does not collapse with inspiration. These findings are highly sensitive and specific for tamponade.
• Hemodynamic Monitoring: Clinical signs such as pulsus paradoxus (an inspiratory decrease in systolic blood pressure greater than 10 mmHg) and elevated jugular venous pressure are important indicators. Hemodynamic monitoring can reveal equalization of diastolic pressures across all cardiac chambers, which is characteristic of tamponade.
• Electrocardiography (ECG): While not definitive, ECG can show low-voltage QRS complexes and electrical alternans, which are suggestive of large pericardial effusion and tamponade.
• Computed Tomography (CT): CT can be useful in complex cases to assess the size and location of the effusion, especially when echocardiography is inconclusive. CT findings include a flattened heart, bowing of the interventricular septum, and enlarged superior and inferior vena cava.

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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.

Treatment

• ABCs
• IV fluids
• Oxygen
• Cardiac monitor
• Vasopressors
• Pericardiocentesis