Advanced Cases

Advanced Cases: Poor Appetite with Dr. Julia Shamis

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


  • 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


Franz, Taylor. “Pericardial Effusion and Cardiac Tamponade: Pearls and Pitfalls.” – Emergency Medicine Education, 4 Apr. 2022, 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:

Farkas, Josh. “Pericardial Tamponade.” EMCrit Project, 10 Nov. 2021,

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

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