Cardiac Tamponade

Case Presentation:

In our #AMReport at @WCHospital (or #WCHMorningReport), we discussed a case of cardiac tamponade in a patient presenting with new-onset exertional dyspnea and low voltage QRS complexes on ECG. Echocardiography revealed a large malignancy-related pericardial effusion and she required urgent pericardiocentesis.

Dyspnea Image-Based Approach:

Approach to dyspnea.pngSource: Jakubovic 2016

Review of the Wells PE Criteria:
Well's Criteria

  • Use these criteria to determine PE probability
  • Scores of <2 indicate low probability; D-dimer prior to additional imaging may be helpful at ruling out VTE in this setting
  • Can also use the PERC Rule to determine who is very low risk

Approach to Elevated D-Dimer:

  • For VTE: 80-85% sensitive, 93-100% negative predictive value
  • Causes of elevated D-Dimer
    • Arterial occlusion (MI, stroke, dissection)
    • VTE (DVT, PE)
    • Systemic disease (beware of false positives): Malignancy, sepsis or infection, pregnancy, trauma etc.

Approach to Low Voltage ECG:

Low Voltage ECG

Etiologies of Cardiac Tamponade:

  • Acute tamponade: ventricular rupture (secondary to trauma, myocardial infarction or iatrogenic), aortic dissection
  • Subacute tamponade:
    • Infection: Viral (HIV), bacterial, TB, Fungal
    • Malignancy: Particularly lung, breast, Hodgkin’s, mesothelioma
    • Inflammatory: SLE, RA, dermatomyositis
    • Post-MI
    • Iatrogenic  or post surgery/procedure
    • Drugs: Hydralazine, procainamide, INH
    • Renal failure (Uremia)
    • Post-radiation
  • Three most common causes of moderate-large pericardial effusions: idiopathic, iatrogenic, malignant

Features of Cardiac Tamponade:


Physical Exam

  • As per the JAMA Rational Clinical Exam series:
    • Pulsus paradoxus >12mmgHg: +LR 5.6, -LR 0.03
      • >10 mmgHg 82% sensitive, + LR 3.3, -LR 0.03
    • Cardiomegaly on CXR: 89% sensitive
    • Low voltages on ECG: only 42% sensitive

Echo Findings

  • Echocardiographic signs suggestive of tamponade include:
    1.  Pericardial effusion
    2. Disatolic RV (high specificity) or RA collapse
    3. IVC dilatation (“plethora”) with minimal respiratory variation (high sensitivity)
      Source: Alerhand & Carter (2019)

Principles of Management of Tamponade:

  • Hemodynamic effects warrant urgent intervention
  • Temporize with IV fluids to help maintain RV patency
  • Transfer to an intensive care setting and pericardiocentesis is the definitive management
  • Identify & treat cause

Additional Reading:

  1. Roy, CL; Minor, MA; Brookhart, A; Choudhry, N. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA. 2007;297(16):1810-1818. doi:10.1001/jama.297.16.1810.
  2. Spodick DH. Acute cardiac tamponade. New England Journal of Medicine. 2003 Aug 14;349(7):684-90.

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