Pericardial effusion and tamponade


  • Always consider in patient with PEA
  • Always consider in patient with penetrating trauma anywhere in the cardiac box (80% result in tamponade)
    • Gun shot wounds are less likely to result in tamponade because pericardial defect is larger
    • Right ventricle is the most commonly injured chamber of the heart due to its anatomic location[1]
  • Pathophysiology
    • Increased pericardial pressure > decreased RV filling > decreased cardiac output


  • Hemopericardium
  • Non-hemopericardium
    • Cancer - most commonly lung, breast, prostate, or hematologic
      • Melanoma has predilection for heart
      • May be related to radiation, infection, chemotherapy
    • Pericarditis
      • Infectious
      • Uremic (renal failure)
    • HIV complications (infection, Kaposi sarcoma, lymphoma)
    • SLE and other autoimmune or connective tissue disorders
    • Post-radiation
    • Myxedema

Clinical Features

  • Chest pain, shortness of breath, cough, fatigue
  • CHF-type appearance
  • Narrow pulse pressure
  • Friction rub
  • Pulsus paradoxus (dec in BP on inspiration)
  • Beck's Triad (33% of patients)

Differential Diagnosis

Chest pain





Pulsus Paradoxus

  • >10mmHg change in systolic BP on inspiration


  • Enlarged cardiac silhouette


  • Often normal
  • Tachycardia (bradycardia is ominous finding)
  • Electrical alternans
  • Low voltage
    • All limb lead QRS amplitudes <5 mm or I+II+III<15;[2]
    • OR All precordial QRS amplitudes <10 mm or V1+V2+V3<30


  • Pericardial effusion
    • In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
    • Differentiate pericardial effusion from pleural effusion using the parasternal long axis view. Pericardial effusions will have an anechoic stripe between the left atrium and descending thoracic aorta. In a pleural effusion, the stripe will be seen behind the descending thoracic aorta.[3]
  • Classical ultrasound findings
    • Diastolic collapse of the right atrium (in atrial diastole)
    • Diastolic collapse of the right ventricle
    • Plethoric IVC (highly sensitive but low specificity)[4]
  • Evaluating systolic vs. diastolic phases with M-mode
    • Position in PSL view with M-mode line through where RV appears to collapse
    • Allow M-mode line to pass through where the anterior MV hits the septum in diastole (much like evaluation of EPSS - see Formal echocardiography)
  • Valvular pulsus paradoxus
    • Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow
    • MV inflow respiratory variation, difference from highest velocity to lowest, as a percentage of highest velocity[5]
      • > 25%, likely tamponade physiology
      • > 40% for tricuspid inflow variation
      • Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients


Hemorrhagic Tamponade

Non-hemorrhagic Tamponade

  • IVF bolus of 500-1000 ml (patient is pre-load dependent)
  • Pericardiocentesis is definitive treatment
  • Dialysis for patients with known renal failure


  • To OR if traumatic and hemodynamically unstable
  • Admit with cardiology/CT surgery consult

See Also


  1. Gunay C, et al. Surgical challenges for urgent approach in penetrating heart injuries. Heart Surg Forum. 2007;10(6):E473-E477. doi:10.1532/HSF98.20071098
  2. Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.
  3. Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982
  4. What echocardiographic findings suggest a pericardial effusion is causing tamponade? Am J Emerg Med. 2019 Feb;37(2):321-326. doi: 10.1016/j.ajem.2018.11.004. Epub 2018 Nov 17.
  5. Rajagopalan N, Garcia MJ, Rodriguez L, Murray RD, Apperson-Hansen C, Stugaard M, Thomas JD, and Klein AL. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol. 2001 Jan 1;87(1):86-94.
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