A 76 year old female with a history of advanced dementia is brought to the ED due to family concerns of poor PO intake for the last 7 days. Vitals are notable for a HR 109 and BP 70/40. On exam, she is cachectic, non-verbal, and somnolent. Point of care cardiac ultrasound demonstrates the following:
Diagnosis: Pericardial Tamponade
Teaching Pearls:
- Presenting signs/symptoms
- Most common symptoms: dyspnea, chest pain, syncope, and altered mental status
- Exam may demonstrate: JVD, tachycardia, hypotension, muffled heart sounds, narrowed pulse pressure, and tachypnea
- Point of care ultrasound findings:
- Effusions can be visualized in all four traditional cardiac views
- Tamponade occurs when the pericardial pressure > intracardiac pressures, resulting in RV collapse in diastole (most specific finding for tamponade)
- Right atrial collapse in early diastole can be first sign of cardiac tamponade (more sensitive but not as specific)
- LV ejection fraction is often high to compensate for decreased filling volume
Treatment:
- IV fluid resuscitation
- In hemodynamically stable patients, treat with pericardiocentesis under fluoroscopy with interventional cardiology or to the OR for pericardial window with cardiothoracic surgery
- If hemodynamically unstable, bedside pericardiocentesis should be performed, ideally under direct ultrasound guidance
- Check out this fantastic youtube video from The Ultrasound Podcast for a review of ultrasound guided pericardioctentesis: Ultrasound Podcast – Pericardiocentesis Microcast! – YouTube
References
Franz, Taylor. “Pericardial Effusion and Cardiac Tamponade: Pearls and Pitfalls.” EmDOCs.net – Emergency Medicine Education, 4 Apr. 2022, www.emdocs.net/pericardial-effusion-and-cardiac-tamponade-pearls-and-pitfalls/. Accessed 12 July 2023.
Stashko E, Meer JM. Cardiac Tamponade. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431090/
Farkas, Josh. “Pericardial Tamponade.” EMCrit Project, 10 Nov. 2021, emcrit.org/ibcc/tamponade/.
Alerhand S, Adrian RJ, Long B, Avila J. Pericardial tamponade: A comprehensive emergency medicine and echocardiography review. Am J Emerg Med. 2022;58:159-174. doi:10.1016/j.ajem.2022.05.001
