From the Guidelines
Pericardial effusion is a life-threatening condition that requires immediate medical attention, and the most concerning red flags include chest pain, shortness of breath, rapid or difficult breathing, and a persistent dry cough, as well as tachycardia, hypotension, muffled heart sounds, and distended neck veins, with pulsus paradoxus being a classic finding 1.
Red Flags of Pericardial Effusion
The red flags of pericardial effusion can be summarized as follows:
- Chest pain that worsens when lying down and improves when leaning forward
- Unexplained shortness of breath
- Rapid or difficult breathing
- Persistent dry cough
- Tachycardia (rapid heart rate)
- Hypotension (low blood pressure)
- Muffled heart sounds (detected during auscultation)
- Distended neck veins (jugular venous distention)
- Pulsus paradoxus, an abnormal decrease in systolic blood pressure during inspiration exceeding 10 mmHg Other red flags include unexplained fatigue, fever (particularly if infection is the cause), swelling in the abdomen or legs, and feeling full after eating small amounts of food due to pressure on surrounding structures.
Diagnosis and Treatment
Diagnosis of pericardial effusion is typically made using echocardiography, which is the single most useful diagnostic tool to identify pericardial effusion and estimate its size, location, and degree of hemodynamic impact 1. Treatment of cardiac tamponade involves drainage of the pericardial fluid, preferably by needle pericardiocentesis, with the use of echocardiographic or fluoroscopic guidance, and should be performed without delay in unstable patients 1.
High-Risk Patients
Patients with recent cardiac procedures, chest trauma, cancer, autoimmune disorders, or infections are at higher risk and should be especially vigilant for these warning signs 1. In summary, pericardial effusion is a serious condition that requires prompt medical attention, and the red flags listed above should be carefully monitored, especially in high-risk patients, to prevent cardiac tamponade and other life-threatening complications 1.
From the Research
Red Flags of Pericardial Effusion
The following are red flags of pericardial effusion:
- Dyspnea 2
- Hypotension 3, 2
- Tachycardia 4
- Jugular venous distension 4
- Pulsus paradoxus 4, 2
- Cardiac chamber collapses 3, 4, 2
- Respiratory variation of the ventricular diameters 3
- Inferior vena cava collapsibility 3
- Flow patterns in atrioventricular valves 3
- Sonographic pulsus paradoxus 2
- Plethoric non-collapsible inferior vena cava 2
Clinical Presentation
Pericardial effusion can present with a range of symptoms, from asymptomatic to life-threatening 5. The most frequently reported symptom is dyspnea 2. The classically taught Beck's triad (which includes hypotension) does not appear commonly 2.
Echocardiographic Findings
Echocardiography is essential to define the location and size of an effusion 5. Echocardiographic findings include:
- Pericardial effusion (larger size associated with tamponade) 2
- Diastolic right ventricular collapse (specific) 2
- Systolic right atrial collapse (sensitive) 2
- A plethoric non-collapsible inferior vena cava (sensitive) 2
- Sonographic pulsus paradoxus 2
Management
Emergent pericardiocentesis is warranted by hemodynamic instability, impending deterioration, or cardiac arrest 2. Pericardial fluid should be drained slowly to avoid pericardial decompression syndrome 2. An understanding of the pathophysiology, clinical presentation, echocardiographic findings, and time-sensitive management of pericardial tamponade is essential for emergency physicians 2.