From the Guidelines
The management of pulsus paradoxus should focus on treating the underlying condition causing this exaggerated drop in blood pressure during inspiration, with initial stabilization using supplemental oxygen and intravenous fluids if needed, as recommended by the European Society of Cardiology guidelines 1. The goal of treatment is to reduce the inspiratory drop in systolic blood pressure to less than 10 mmHg, which indicates resolution of the pathophysiologic process causing ventricular interdependence and impaired cardiac filling.
Causes and Treatment
Some of the common causes of pulsus paradoxus include:
- Cardiac tamponade, which requires emergency pericardiocentesis using a large-bore needle inserted into the pericardial space under ultrasound guidance to drain the fluid compressing the heart, as outlined in the guidelines on the diagnosis and management of pericardial diseases 1
- Severe asthma or COPD exacerbations, which can be treated with bronchodilators such as albuterol, systemic corticosteroids, and possibly magnesium sulfate for severe cases
- Tension pneumothorax, which requires immediate needle decompression with a 14-16 gauge needle in the second intercostal space at the midclavicular line followed by chest tube placement
- Constrictive pericarditis, which may require pericardiectomy if medical management fails
Monitoring and Treatment Adjustment
Continuous hemodynamic monitoring is essential during treatment, as pulsus paradoxus serves as a clinical marker of disease severity and response to therapy. The treatment plan should be adjusted based on the patient's response to therapy, with the goal of reducing the inspiratory drop in systolic blood pressure to less than 10 mmHg. This can be achieved by closely monitoring the patient's blood pressure, respiratory rate, and overall clinical condition, and making adjustments to the treatment plan as needed, as recommended by the European Society of Cardiology guidelines 1.
From the Research
Definition and Causes of Pulsus Paradoxus
- Pulsus paradoxus is defined as a decline in the systemic systolic blood pressure by more than 10 mmHg during inspiration 2.
- It can be observed in cardiac tamponade and in conditions where intrathoracic pressure swings are exaggerated or the right ventricle is distended, such as severe acute asthma or exacerbations of chronic obstructive pulmonary disease 3.
- The main clinical situations in which a paradoxical pulse may be observed are inflow obstruction into the heart (as in exsudative pericarditis or cardiac tamponade) or extreme respiratory variations in intrathoracal pressure (as during an asthma attack) 2.
Clinical Significance and Diagnosis
- Pulsus paradoxus is an exaggerated fall in systolic blood pressure with inspiration (usually greater than 10 mm) 4.
- Early recognition of pulsus paradoxus in the emergency room can help to diagnose rapidly cardiac tamponade 3.
- Measurement of pulsus paradoxus is also useful to assess the severity of acute asthma as well as its response to therapy 3.
- Echocardiography (M-mode, 2-D, and Doppler) has aided considerably our understanding of pulsus paradoxus 4.
Management and Assessment
- The management of pulsus paradoxus involves addressing the underlying cause, such as cardiac tamponade or severe acute asthma 3.
- Recent development of noninvasive devices capable of automatic calculation and display of arterial pressure variation or derived indices should help improve the assessment of pulsus paradoxus at the bedside 3.
- Understanding the accuracy of pulsus paradoxus for a diagnosis of cardiac tamponade requires a consideration of the mechanisms underlying its genesis, and a knowledge of its presence in other conditions and its variable absence in cardiac tamponade with associated disease states 4.