(NEJM 2003;349:684)
Approach
• IV fluid bolus: Pts are preload dependent
• Bedside pericardiocentesis if HD unstable
Definition
• Fluid accumulation in the pericardial sac → pericardial pressure exceeds RV filling pressure → equalization of pressures in all cardiac chambers → decreased filling pressures & CO
History
• Penetrating or blunt trauma, see pericardial effusion (above) for other causes
Findings
• ↑ HR, ↑ RR, Beck’s triad (↓ BP, distended neck veins, muffled heart sounds), narrow pulse pressure, pulsus paradoxus (see how to perform clinically above)
Evaluation
• ECG: Low voltage, electrical alternans, ± signs of pericarditis
• CXR: Globular heart, but may be nl if rapid accumulation (eg, trauma)
• Echo: Confirms the Dx. Effusion, septal shift, late diastolic collapse of RA, persistence of RA collapse >1/3 cardiac cycle, early diastolic collapse of RV, collapse of LA, dilated IVC w/ <50% respiratory collapse.
Treatment
• IV fluids: Aggressive fluid boluses (pts are preload dependent), though excess fluid can worsen tamponade
• Pericardiocentesis done @ bedside if pt is unstable, otherwise should be done in OR
Disposition
• Admission either directly to the OR or ICU
Pearls
• ↑ morbidity w/ rapid fluid accumulation (2° poor pericardial compliance)
• If a/w penetrating trauma, effusion may be clotted blood (may require thoracotomy)