Pericardial effusions may develop rapidly (acute) or more gradually (subacute or chronic). With time, the intrapericardial pressure increases and can impede cardiac filling, resulting in impaired cardiac function (i.e. cardiac tamponade and obstructive shock).

Etiology¹

• Infection – acute pericarditis (viral, bacterial, fungal, parasitic).
• Autoimmune disease – e.g. lupus, rheumatoid arthritis, scleroderma, Sjögren syndrome.
• Post-myocardial infarction or cardiac surgery.
• Neoplasm – metastatic (e.g. lung, breast) more common than primary.
• Trauma – blunt or penetrating, iatrogenic.
• Metabolic – hypothyroidism, uremia.
• Mediastinal radiation.
• Cardiac causes – postcardiac injury syndrome, myocarditis, dissecting aortic aneurysm.
• Medications.

Signs and symptoms are insensitive and nonspecific for mild pericardial effusions but become more useful in the diagnosis of cardiac tamponade.

Almost all patients with cardiac tamponade have one or more of the following:

• sinus tachycardia.
• elevated jugular venous pressure.
• pulsus paradoxus (>10mmHg decrease in systolic blood pressure on inspiration).

Beck’s triad of low arterial blood pressure, dilated neck veins, and muffled heart sounds, are present in only a minority of cases of acute cardiac tamponade.²

A pericardial rub may be heard in patients with cardiac tamponade due to inflammatory pericarditis.³

ECG – sinus tachycardia, low QRS voltage, and electrical alternans.

CXR – Effusions > 200-300 mL typically present with an enlarged cardiac silhouette.

1. Confirm pericardial effusion.

•  After an ECG and CXR are done, a point-of-care cardiac ultrasound (POCUS) can be used to confirm the diagnosis of a pericardial effusion with 96-100% sensitivity and specificity.⁴ A formal echocardiogram can also be used to establish the diagnosis.⁵ POCUS can help as follows:
  • Cardiac views – to confirm the presence of a pericardial effusion
  • IVC views – collapsible IVC (>50% collapse with sniffing or throughout the respiratory cycle) effectively rules out tamponade. A distended IVC with pericardial effusion is suggestive, although not definitively diagnostic, of cardiac tamponade.
  • The size of the effusion is graded on the echocardiogram as:
    • small ~ 50-100mL
    • medium ~ 100-500mL
    • large = >500mL

2. Assess hemodynamic impact.

• Factors that determine the degree of hemodynamic compromise:
  • size of the effusion.
  • rate of fluid accumulation (acute versus subacute/chronic).
  • whether the pericardium is scarred or adherent.⁶
• Acute cardiac tamponade – within minutes – usually due to penetrating trauma (including iatrogenic), or rupture of the heart or aorta resulting in obstructive shock (hypotension, cool extremities, peripheral cyanosis). It can be confused with cardiogenic shock as associated with chest pain, dyspnea, tachypnea, muted heart sounds, and venous distension.
• Subacute cardiac tamponade – days to weeks – chest pain, dyspnea, fatigue, peripheral edema, and hypotension with a narrow pulse pressure.
• Peripheral edema may be seen with more chronic cardiac tamponade.⁷

3. Establish the cause.

•  Often the cause of the pericardial effusion is evident based on history.⁸
  • When history and physical exam are not suggestive of a specific diagnosis, routine lab investigations including CBC, chemistry profile, renal function, TSH can be helpful. ANA should be considered in young women with an effusion and associated acute pericarditis.
• Pericardial fluid analysis and/or pericardium biopsy may be needed to establish the diagnosis:
  • gram stain.
  • bacterial/fungal cultures.
  • cytology.
  • AFB stain.
  • mycobacterial culture.⁸

Pericardial fluid drainage can be diagnostic as well therapeutic.

In ED done for urgent relief of hemodynamic compromise using percutaneous catheter (pericardiocentesis) under US guidance.

Alternately echocardiogram guided pericardiocentesis or an open surgical drainage if subacute or chronic.

The indications for urgent pericardial fluid drainage depend on the patient’s hemodynamic compromise.⁵

• Hemodynamically stable = supportive care. Optimize preload (IV fluids, ionotropic agents) and minimizing intrathoracic pressure by minimizing inspiratory pressures in intubated patients.
• If clinical and point-of-care cardiac ultrasound findings indicate hemodynamic compromise → urgent pericardial drainage is needed.
• Pericardiocentesis under echocardiographic guidance is recommended for most patients.
• Surgical drainage is recommended if:
  • Bleeding into pericardium from trauma or aortic dissection.
  • Post-infarction ventricular wall rupture.
  • Reaccumulation of fluid after previous pericardiocentesis.
  • Suspicion of purulent pericarditis.
  • Need for pericardial biopsy.
  • Pericardial effusion is loculated.
• Percutaneous echo-guided pericardiocentesis may be required prior to GA for surgical drainage as GA may worsen hemodynamic compromise.
• Relative contraindications for pericardiocentesis include:
  • PASP >70mmHg (not an ED issue).
  • Uncorrected bleeding diathesis.
• Patients with small to moderate pericardial effusions who are hemodynamically stable and without a need for diagnostic fluid sampling can be monitored with serial examinations and echocardiograms.

1. Cardiac catheterization lab – if urgent echo-guided percutaneous pericardiocentesis is needed.
2. Operating room – if urgent surgical drainage is needed (see indications above).
3. Cardiology inpatient service – for patients who do not need urgent pericardial fluid drainage but may require drainage for diagnostic purposes or at the least need to be monitored with serial examinations and echocardiograms.

1. 1. Imazio M. Contemporary management of pericardial diseases. Curr Opin Cardiol 2012; 27:308.

   
   

2. 2. Beck, CS . Two cardiac compression triads. J Am Med Assoc 1935; 104:714.

   
   

3. 3. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004; 363:717.

   
   

4. 4. Gibbons, Ryan. “Pericardial Effusion.” Society of Academic Emergency Medicine, 2020, https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m3-curriculum/bedside-ultrasonagraphy/pericardial-effusion.

   
   

5. 5. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.

   
   

6. 6. Shabetai R. Pericardial effusion: haemodynamic spectrum. Heart 2004; 90:255.

   
   

7. 7. Brown J, MacKinnon D, King A, Vanderbush E. Elevated arterial blood pressure in cardiac tamponade. N Engl J Med 1992; 327:463.

   
   

8. 8. Sagristà-Sauleda J, Mercé J, Permanyer-Miralda G, Soler-Soler J. Clinical clues to the causes of large pericardial effusions. Am J Med 2000; 109:95.

   
   

1. Emergency pericardiocentesis video

   
   

2. Point-of-care ultrasound for diagnosis of cardiac tamponade

   
   

3. Ultrasound-guided pericardiocentesis