Rosen & Barkin's 5-Minute Emergency Medicine Consult (525 page)

• ECG
  
• CXR
  
• US:
  
  • Echocardiography, including evaluation of aortic root
    
  • Shock US: Include focused assessment with sonography in trauma, aorta, pleural effusion, and pneumothorax views to rule out other causes of hypotension
    

• CBC
  
• ESR, C-reactive protein:
  
  • Usually elevated in pericarditis
    
• Cardiac enzymes:
  
  • Consider myocarditis if elevated
    
• Electrolytes:
  
  • BUN/creatinine in suspected uremic pericarditis
    
• Coagulation profile:
  
  • Especially in liver failure, anticoagulation, trauma
    
• Blood cultures if an infectious source is suspected
  

• Chest radiograph:
  
  • Cardiomegaly is 89% sensitive for tamponade.
    
  • Can be normal even with effusion if developed quickly
    
• Echocardiography:
  
  • 97–100% sensitive, 90–97% specific
    
  • Effusion: Can detect as little as 20–50 cc of pericardial blood/fluid:
    
    • Small effusions will only be seen posteriorly.
      
    • Anterior fat pad may mimic effusion; must also visualize posterior pericardial space for diagnosis of effusion.
      
  • Tamponade:
    
    • Effusions large enough to cause tamponade should be circumferential.
      
    • Right atrial or ventricular bowing and eventual collapse
      
    • “Sniff” test: During inspiration, the inferior vena cava will not collapse in patients with tamponade.
      
• Chest CT for detecting hemopericardium
  
• Transesophageal echocardiography
  
• MRI with gadolinium (for stable patients only)
  

• ECG:
  
  • Low voltage
    
  • Electrical alternans: Alternating beat-to-beat variation of QRS amplitude (usually only seen with large effusions)
    
• Pericardiocentesis and fluid analysis:
  
  • Therapeutic for tamponade or large symptomatic effusion
    
  • Diagnostic for bacterial effusion (to guide antibiotics) or malignant effusion (for cytology)
    
• Central venous pressure (CVP) determination:
  
  • CVP >15 cm H
    ₂
    O suggests tamponade, but may be normal in the hypovolemic patient.
    

• Noncardiogenic shock:
  
  • Hypovolemic, septic, anaphylactic, spinal
    
• Other cardiac conditions:
  
  • Myocardial infarction—common misdiagnosis!
    
  • Pericardial constriction (due to pericardial fibrosis)
    
  • CHF
    
• Pulmonary conditions:
  
  • Pulmonary embolus
    
  • Tension pneumothorax
    
  • Hemothorax
    
• Other causes:
  
  • Air embolism
    
  • Aortic dissection
    
  • Ruptured abdominal aortic aneurysm
    

TREATMENT

• 2 large-bore IV lines
  
• Start IV fluids.
  
• Supplemental O
  ₂
  

• Continue pre-hospital measures
  
• Continuous cardiac monitoring
  
• In tamponade:
  
  • IV fluid resuscitation with normal saline or blood
    
  • Pericardiocentesis for unstable patients to decompress the tamponade
    

• Medical causes of tamponade in patients who are unstable:
  
  • Perform pericardiocentesis with placement of an indwelling catheter for continued drainage:
    
    • Site of drainage guided by maximum fluid collection
      
    • Subxiphoid: 2 cm below and 1 cm to the left of the xiphoid process, needle aimed at 30–45° angle toward the patient’s left shoulder
      
    • Left parasternal approach: 5th intercostal space just lateral to sternum, needle inserted perpendicular to the skin
      
    • Remove fluid as needed to improve clinical condition.
      
• Traumatic pericardial tamponade:
  
  • Consult trauma surgeon immediately.
    
  • Definitive therapy is thoracotomy in the OR.
    
  • If patient is deteriorating despite resuscitation, ED thoracotomy with pericardotomy is an option.
    
• Bacterial pericardial effusion:
  
  • Initiate antibiotic therapy to cover gram-negative and anaerobic organisms and
    Staphylococcus aureus
    .
    
  • May ultimately require partial surgical resection of the pericardium
    
• Uremic pericardial effusion:
  
  • Arrange urgent dialysis.
    
• Dressler syndrome and postirradiation pericardial effusion:
  
  • Initiate aspirin
    
• Aortic dissection:
  
  • Immediate cardiothoracic surgical consultation for operative repair
    

• Ibuprofen: 800 mg PO q8h
  
• Indomethacin: 75–150 mg PO daily
  
• Avoid NSAIDs in patients with CAD
  
• Steroids:
  
  • Only for refractory cases (more commonly associated with rebound when tapered)
    
  • Prednisone: 0.2–0.5 mg/kg, continued for at least 1 mo, slowly tapered
    

FOLLOW-UP

• ICU admission for acute, symptomatic pericardial effusion/tamponade
  
• New pericardial effusion
  
• Pericarditis with elevated troponin
  

• Known or incidentally found small pericardial effusion in asymptomatic stable patient
  
• Pericarditis without evidence of tamponade in a young, healthy person whose pain is controlled with NSAIDs
  

• Trauma surgery:
  
  • Tamponade in setting of trauma: Will need to go to OR for thoracotomy (or from ED status post ED thoracotomy)
    
• Cardiothoracic surgery:
  
  • Tamponade/effusion in the setting of aortic dissection/other primary cardiac problem
    
  • Patients requiring pericardial window
    
  • Any patients who have had recent cardiac surgery
    
• Cardiology/interventional cardiology:
  
  • Dressler syndrome
    
  • Recent percutaneous intervention
    
  • Any patients who need pericardiocentesis
    

Discharged patients need urgent primary care physician follow-up and repeat echo to evaluate for resolution of effusion.

• ECG changes associated with pericarditis include diffuse ST-elevation with PR-depression and eventual T-wave inversion. Should be contrasted with ECG findings of localized ST-elevation with reciprocal ST-depression in AMI.
  
• Relatively small effusions can cause tamponade if rapidly developing (conversely, large effusions can be relatively benign when they develop slowly).
  
• Cardiac output can be fluid dependent in tamponade—start fluids early.
  
• Use bedside US to look for pericardial effusion and other signs of tamponade in the setting of hypotension (including trauma).
  
• ED thoracotomy should not be employed if there is no OR readily available.
  

• Bessen HA, Byyne R. Acute pericarditis and cardiac tamponade. In: Wolfson AB, ed.
  Harwood Nuss’ Clinical Practice of Emergency Medicine
  . 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:507–510.
  
• Hoit BD. Pericardial disease and pericardial tamponade.
  Crit Care Med
  . 2007;35(8):S355–S364.
  
• Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases.
  Circulation
  . 2010;121:916–928.
  
• Little WC, Freeman GL. Pericardial disease.
  Circulation
  . 2006;113:1622–1632.
  
• Roy CL, Minor MA, Brookhart MA, et al. Does this patient with a pericardial effusion have cardiac tamponade?
  JAMA
  . 2007;297(16):1810–1818.
  
• Shockley LW. Penetrating chest trauma. In: Wolfson AB, ed.
  Harwood Nuss’ Clinical Practice of Emergency Medicine
  . 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:990–999.
  

See Also (Topic, Algorithm, Electronic Media Element)

Cardiogenic Shock

CODES

• 423.3 Cardiac tamponade
  
• 423.9 Unspecified disease of pericardium
  

BASICS