Pericardial Tamponade

Educational Objectives

The goal of this program is to improve the management of pericardial tamponade. After hearing and assimilating this program, the clinician will be better able to:

1. Use pericardial ultrasonography to assess a plethoric inferior vena cava.

2. Select effective treatment of patients with shock and a plethoric inferior vena cava.

3. Differentiate pericardial tamponade from pericardial effusion.

Summary

Indications for pericardial ultrasonography: shortness of breath (SOB; especially unexplained SOB), change in exercise tolerance, chest pain, abnormal vital signs, tachycardia, and hypotension; assess the inferior vena cava (IVC); pericardial tamponade is defined as low blood pressure with evidence of right ventricular (RV) collapse during diastole; a plethoric IVC is a clue

Mnemonic for types of shock: S — septic or spinal (neurogenic); H — hypovolemic or hemorrhagic; O — obstructive; due to, eg, pericardial tamponade, pulmonary embolism, tension pneumothorax; C — cardiogenic shock or compartment syndrome; K — “endoKrine” or “anaphylaKtic”

Plethoric IVC: ultrasonography technique — visualize the heart in the subxiphoid view and identify the IVC; rotate the probe (a curvilinear, phased array, or cardiac probe can be used) 90 degrees to locate the point in which the IVC enters the right atrium (RA); IVC diameter — a plethoric IVC does not change with respiratory variation; a >50% variation in IVC size with respiration indicates that such patients would benefit from fluids; one way to measure the IVC and evaluate fluid status is to take an IVC measurement and then repeat it after a small bolus; another way is to ask the patient to perform a passive leg raise, which passes boluses (250-500 mL) into the abdomen, thorax, and circulatory system; patients with septic, spinal, hypovolemic, hemorrhagic, endocrine, or anaphylactic shock should not have a plethoric IVC; a plethoric IVC is seen in patients with obstructive and cardiogenic shock

Management of various types of shock: hypovolemic and hemorrhagic shock — general treatment (ie, fluids, antibiotics, vasopressors) is effective; anaphylactic shock — epinephrine; septic or spinal shock — general treatment; endocrine shock — check for adrenal insufficiency or other type of endocrinopathy

Differential diagnosis of plethoric IVC: cardiac tamponade — may respond to fluids; pericardiocentesis is required; pulmonary embolism — initially responds to general treatment, but rapid clot removal (with, eg, tissue plasminogen activator) and anticoagulation therapy is necessary; tension pneumothorax — fluids may be helpful, but patients need a finger or needle thoracostomy; cardiogenic shock — fluids worsen outcome

Pericardiocentesis in the emergency department: “blind” approach — approach from a subxiphoid angle; at 45 degrees to the midsagittal plane, point the needle towards the patient’s left shoulder; raise the needle above the horizontal axis ≈45 degrees to the abdominal wall; slowly advance the needle until straw-colored fluid (pericardial effusion) is seen; in cases of hemorrhagic pericardial effusion, bleeding or a clot might pose challenges; withdrawal of 10 to 30 mL of fluid should improve vital signs; some practitioners advocate removing the needle or leaving a single-lumen catheter in place; patients must undergo an emergent pericardial window; ultrasonographic approach — safer than the blind approach; a subxiphoid approach works well; other options include approaching from the right or left fifth intercostal space or at the apex; recommended to approach from the angle that provides the most space between the cardiac wall and pericardial sac; once the pericardial sac has been penetrated, a small amount of agitated saline can be injected to test for correct placement; a lidocaine injection or other form of sedation (eg, ketamine; avoid propofol) can improve the patient’s comfort level; the procedure should be followed by emergent cardiology care

Pericardial effusion: general presentation — SOB; hypotension; generalized weakness; change in exercise tolerance; palpitations (less common); examination findings — Beck triad; tachycardia; tachypnea; hypotension; jugular venous distention; pulsus paradoxus (drop in systolic blood pressure with respiration); distant heart sounds; imaging studies may show a water bottle sign in which the heart appears uniformly large with an increased angle (stretching) at the pericardium; electrical alternans is a classic finding on electrocardiography (ECG); voltage may be decreased in all the leads as fluid surrounding the heart dampens the electrical signal; causes — radiation; uremia; myxedema; cancer; hemorrhage; infection; pericarditis; systemic lupus erythematous (SLE); may be idiopathic; among nontrauma patients, ≈40% of cases of pericardial tamponade are due to metastatic malignancies; 25% are idiopathic; 10% are due to uremia; 10% are caused by bacterial infection or tuberculosis; 5% are associated with hemorrhage; 10% are due to some other cause (eg, SLE); risk factors — cancer (consider pericardial effusion in patients with alopecia and cachexia associated with chemotherapy); malar rash or other signs of SLE; uremia; chest trauma; undifferentiated tachycardia

Differentiating pericardial tamponade from effusion on ultrasonography: 97% of the time, patients with pericardial tamponade also have a plethoric IVC; RV collapse during diastole — on a parasternal long view, look at the left and right ventricular walls at the same time; check for RV collapse as the left ventricle expands; or use the M-mode display to set a line through the RV wall and anterior leaflet of the mitral valve in order to obtain a graphical depiction of movement in the heart; check for RV collapse or movement away from the probe during diastole (ie, when the anterior leaflet is open or closer to the probe or septum); right atrial collapse during early systole or late diastole — the earliest ultrasonographic sign of tamponade; the RV outflow tract can be observed to check for anterior wall collapse during diastole; “the real big clue is the plethoric IVC”

Readings

Fink RJ. Pneumopericardium causing pericardial tamponade. Clin Case Rep. 2020 Aug 10;8(12):3571-3572. doi:10.1002/ccr3.3233; Harada K et al. Pericardial tamponade during pembrolizumab treatment in a patient with advanced lung adenocarcinoma: a case report and review of the literature. Thorac Cancer. 2020;11(5):1350-1353. doi:10.1111/1759-7714.13399; Honasoge AP, Dubbs SB. Rapid fire: pericardial effusion and tamponade. Emerg Med Clin North Am. 2018;36(3):557-565. doi:10.1016/j.emc.2018.04.004; Marik PE, Weinmann M. Optimizing fluid therapy in shock. Curr Opin Crit Care. 2019;25(3):246-251. doi:10.1097/MCC.0000000000000604; McLean AS. Echocardiography in shock management. Crit Care. 2016 Aug 20;20:275. doi:10.1186/s13054-016-1401-7; Stashko E, Meer JM. Cardiac tamponade. StatPearls Publishing. 2020 Nov 18; Takamatsu K et al. Air pericardial tamponade caused by lung cancer. Intern Med. 2020;59(23):3109-3110. doi:10.2169/internalmedicine.5247-20; Vakamudi S et al. Pericardial effusions: causes, diagnosis, and management. Prog Cardiovasc Dis. 2017;59(4):380-388. doi:10.1016/j.pcad.2016.12.009.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Grock was recorded at the Vermont Emergency Medicine Update, held January 27-29, 2020, in Stowe, VT, and presented by the Larner College of Medicine at the University of Vermont. For information about CME offerings from this presenter, please visit med.uvm.edu/cme/home. Audio Digest thanks the speakers and Larner College of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

EM381201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.