Pericardial effusion

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 Pericardial effusion

🔹 Definition

  • Pericardial effusion: Accumulation of fluid in the pericardial space (serous, serosanguinous, or hemorrhagic).

  • Cardiac tamponade: Hemodynamically significant increase in intrapericardial pressure → impaired cardiac filling → ↓ cardiac output → obstructive shock.

🔹 Etiology

Hemorrhagic (Hemopericardium)

  • Cardiac wall rupture (post-MI)

  • Trauma (blunt, penetrating)

  • Aortic dissection

  • Post cardiac surgery

Serous/Serosanguinous

  • Idiopathic / viral pericarditis

  • Bacterial, tuberculous, fungal infection

  • Malignancy (lung, breast, lymphoma, leukemia, melanoma)

  • Uremia

  • Autoimmune (RA, SLE)

  • Hypothyroidism (myxedema)

  • Post-pericardiotomy syndrome

  • Right heart failure

🔹 Pathophysiology

  • ↑ Pericardial pressure → heart compression (RV most affected first due to thin wall)

  • ↓ Venous return + ↓ diastolic filling → ↓ stroke volume → ↓ cardiac output

  • Equalization of diastolic pressures in all 4 chambers

  • Septal shift impedes LV filling → pulsus paradoxus

🔹 Clinical Features

Pericardial effusion (may be asymptomatic)

  • Dyspnea, orthopnea, retrosternal discomfort

  • Dysphagia, hoarseness, hiccups (compressive symptoms)

  • Dullness to percussion at left lung base (Ewart sign)

  • Apical impulse poorly palpable

Cardiac tamponade

  • Beck triad: Hypotension + JVD + muffled heart sounds

  • Tachycardia, pulsus paradoxus (>10–12 mmHg drop in SBP with inspiration)

  • Cold extremities, diaphoresis

  • Signs of obstructive shock or PEA arrest


🔹 Diagnosis

Echocardiography (Gold standard)

  • Anechoic pericardial space

  • Effusion grading:

    • Small (<10 mm ≈ 300 mL)

    • Moderate (10–20 mm ≈ 500 mL)

    • Large (>20 mm >700 mL)

  • Tamponade signs: RA systolic collapse, RV diastolic collapse, IVC plethora, septal bounce, swinging heart

ECG

  • Small effusion: often normal

  • Large effusion: low voltage QRS, sinus tachycardia, electrical alternans


  • Cardiac arrest: PEA

CXR

  • Water bottle sign (large effusion)


  • Normal if <250 mL

Pericardial fluid analysis

  • Transudate: HF, renal failure, hypoalbuminemia

  • Exudate: infection, inflammation, malignancy, autoimmune

  • Hemorrhagic: trauma, rupture, dissection, TB, malignancy

  • Purulent: bacterial, TB

🔹 Management

General

  • Treat underlying cause

  • Admit and monitor (telemetry, BP, pulsus paradoxus)

  • Avoid positive pressure ventilation and anesthetics if possible (reduce preload further)

Stable effusion

  • Small: observation + treat cause

  • Large, symptomatic, unclear cause: pericardiocentesis or pericardial window

Unstable (tamponade / shock)

  • Immediate pericardial decompression:

    • Pericardiocentesis (echo-guided preferred; blind if arrest/no US available)

    • Surgical drainage (pericardial window, pericardiectomy) if traumatic, purulent, malignant, or rapidly re-accumulating

Hemodynamic support

  • IV access x2, cautious fluids (only hypovolemic)

  • Inotropes (dobutamine) if needed

  • Avoid intubation unless absolutely necessary

🔹 Emergency Checklist (Acute Tamponade)

  1. Call cardiology / cardiothoracic surgery

  2. FoCUS if stable (skip if unstable)

  3. Urgent pericardiocentesis if unstable

  4. Fluids (cautious), inotropes if shock persists

  5. Continuous telemetry + ICU admission

  6. Serial pulsus paradoxus monitoring

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