46 YOF with a pmhx notable
adenocarcinoma of the breast
presents with 3 days
increasing dyspnea with
exertion and generalized
weakness. She denies chest
pain, cough/congestion, any
fevers/chills. She is currently
courses and is not currently
treatment. She presents
awake/alert, in no respiratory
T 97.7 P 105 BP 110/80
O2 96% RR 20
Gen: WDWN, thin
CV: Tachycardic, RR,
Pulm: Lungs CTA bilat,
chest wall shows left-
Neck – no JVD, trachea
Abd – s/nt/nd
Ext – warm, no cy/cl/ed
-Pericardial effusion causes an enlarged heart shadow that is often globular
shaped (transverse diameter is disproportionately increased).
-A lateral film and close-up of a pericardial effusion showing the anterior
mediastinal fat (blue arrows) and epicardial fat (red arrows) separated by a
soft tissue stripe ( "fat pad" sign) reflecting the pericardial effusion seen
IV Fluid resuscitation
Treatment consists of emergency pericardiocentesis
when there is hemodynamic compromise.
Admission for management of underlying disease state
vs. intervention to address fluid collection.
Although an effusion is often described as producing a globular-shaped
heart, it is usually not possible to differentiate a pericardial effusion from
cardiac enlargement on a chest radiograph
Approximately 250 ml of fluid must be in the pericardium to lead to a
detectable change in the size of the heart shadow on PA CXR
small effusions (100–200 mL) may not cause cardiomegaly even though
they can cause tamponade when they accumulate rapidly or when the
pericardial membrane is stiffened from fibrosis
Pericardial effusion can be definitively diagnosed with either
echocardiography (can be bedside in the emergency department in the
critically ill patient patient) or CT
In the postoperative patient a pericardial effusion can be a sign of bleeding,
necessitating a return to the OR.
Beck's triad (1) systemic hypotension, (2) elevated systemic venous
pressure, and (3) muffled heart sounds is typical of acute tamponade which
may be due to abrupt intrapericardial hemorrhage from penetrating
trauma, invasive cardiac procedures, or rupture of an ascending aortic
dissection or myocardial infarction. The complete triad is rarely
Tamponade has a spectrum of presentations ranging from circulatory
collapse to mildly reduced cardiac output with symptoms of dyspnea and
chest or abdominal discomfort depending on the rate of fluid
Pulsus paradoxicus, an accentuated fall in the systolic pulse
pressure (>10 mm Hg) during inspiration, is not present in one-
quarter of patients with tamponade.
EKG in the setting of tamponade often shows sinus rhythm with
low voltage (QRS amplitude in the limb leads <5 mm) suggestive
of tamponade physiology.
Electrical alternans, a more specific sign of tamponade occurs
when there is a very large pericardial effusion in which the heart
swings during cardiac contraction causing a beat-to-beat variation
in the EKG axis (QRS amplitude).
Echocardiogram (long axis left parasternal
view) confirming a moderate pericardial
effusion (1 cm thickness) both anterior and
posterior to the heart (arrows).
EKG showing low voltage in the limb
leads (<5 mm). There is slight beat-
to-beat variation in the QRS
amplitude of leads V1, V4 and V5
EKG after pericardiocentesis and
drainage of the pericardial effusion
showing increased QRS amplitude.