1. PERICARDIAL EFFUSION &
CARDIAC TAMPONADE
by DR. AVINASH PRAKASH

5. IMPORTANT POINTS
• Definition
• Patho-physiology
• etiology
• Clinical features
• Investigations
• Treatment

6. DEFINITION
PERICARDIAL EFFUSION
“an abnormal accumulation of fluid
in the pericardial cavity”
CARDIAC TAMPONADE
“clinical syndrome caused by accumulation of
fluid in the pericardial space,
resulting in reduced ventricular filling and
subsequent hemodynamic compromise”

7. PATHO-PHYSIOLOGY
↑ Pressure
pericardi on rt side
al fluid of heart
Pooling
of blood
↓Venous
in pulm
return
capillari
es
↓Stroke
volume, Cardiac
Arrest
↓CO
How much pericardial fluid is needed to

8. Pericardial Pressure-
Volume Relation

9. ETIOLOGY: blood/ pus/serous
• hypothyroidism
• physical trauma
• Pericarditis (bact/TB/HIV)
• myocardial rupture
• after heart surgery
• aortic dissection
• neoplastic

10. CLINICAL SYMPTOMS
• Breathles
sness
• Chest
pain,
• Abdomina
l pain,
• Fatigue,
• Fever,
• Cough,
• Palpitati
on,
• Maybe in

11. PHYSICAL EXAMINATION
• tachycardia,
• distant or muffled
heart sounds
• jugular vein
distension
• falling BP,
• paradoxical pulse
(a drop in inspiratory
BP by greater than 10
mmHg).

12. Beck's triad.(rapid accumulation of pericardial fluid)
1. Hypotension occurs because of decreased stroke volume
2. jugular-venous distension due to impaired venous return to the heart
3. muffled heart sounds due to fluid inside the pericardium

13. INVESTIGATIONS
• complete blood
count (CBC)
• RFT,LFT
• PT,INR
• CKMB, TROP-T
• ANA assay,
• ESR
• Rh FACTOR
• HIV testing
• Mantoux test
• Pericardial fluid

14. ECG • sinus tachy ,low voltage QRS complexes ,
• electrical alterans,

15. CXR: large, globular heart, enlarge cardiac
silhouette, water bottle shaped heart

16. ECHO: “diagnostic test of choice “

18. TREATMENT: PERICARDIAL EFFUSION
The mortality and
MEDICINE morbidity of
• NSAIDS/Aspirin : for most pericarditis effusion is
pericardial
• Colchicine: COPE trial dependent upon
etiology and comorbid
• Systemic steroids: causes recurrence ; only if unre
conditions
• Hemodynamic support : IVF, Inotropes
• Pus? – drain+ i.v. antibacterial therapy
• TB- ATT+ iv predni 1-2 mg/kg x 7 d
• Antineoplastic therapy
SURGERY (if S/S persist)
• Pericardial sclerosis (tetra , doxy ,cisplatin,5 –FU
• Sub-xiphoid pericardial window with pericardiost
• Thoracotomy: pleuro-pericardial window
• Video-assisted thoracic surgery

19. TREATMENT: PERICARDIAL EFFUSION
Mild/asympt
No Rx;
o/
f/u ECHO
incidental
Known
Medium/ cause Tampona
large de
No cause
Idiopathi
c

20. TREATMENT: PERICARDIAL EFFUSION
Pericardiocentesi
S/S s/
Sx Drainage
Known Treat the
cause cause
Asympt Asirin/
o NSAIDS
No role for elective pericardiocentesis in asymptomatic ,
unless for diagnosis or if pus / TB Diagnostic
pericardiocentesis

21. TREATMENT: PERICARDIAL EFFUSION
Large effusion x 3 months
Remove as much as possible
Elective
Idiopathic Recurrence
pericardioce ?
Chronic
ntesis
Repeat
Pericardie Recurrence
Pericardiocen
ctomy ?
tesis

22. TREATMENT: CARDIAC TAMPONADE
Cardiac tamponade is a medical emergency
Untreated, cardiac tamponade is rapidly
and universally fatal
Prompt diagnosis and treatment is the key.
• O2
• Volume expansion
• Bed rest
• Inotropic drugs
• Positive-pressure mechanical
ventilation should be avoided
• Pericardiocentesis:
• A Swan-Ganz catheter can be left in
place for continuous monitoring of
hemodynamics

23. PERICARDIOCENTESIS
Equipment
1. Bed side ECHO
2. ECG
3. 18 gauge spinal needle
4. 3 way
5. 20 cc syringe
6. A wire with alligator clips

24. PERICARDIOCENTESIS
PREPARATION:
1. surface
landmarks
2. Clean
3. Drape
4. LA
5. Raise the
head of the
bed

25. PERICARDIOCENTESIS
APPROACH
1. Sub-xiphoid :
A. Echo
guided
B. ECG
guided
C. Blind
2. Para-
sternal

27. PERICARDIOCENTESIS
AFTER CARE
1. Monitor vitals
2. Look out for complications
3. Repeat ECHO & CXR
4. If Pt still symptomatic then may require
placement of catheter in the pericardial
space or surgical creation of a
pericardial window

28. PERICARDIOCENTESIS
COMPLICATIONS
1. Cardiac arrhythmia
2. Pneumothorax
3. Pleural effusion
4. Myocardial injury
5. Peritoneal injury
6. Liver/stomach injury
7. Internal mammary artery injury
8. Diaphragmatic injury

29. RECURRENT TAMPONADE
• pericardial window
• Sclerosing the pericardium
• Pericardio-peritoneal shunt
• Pericardiectomy

30. • Signs & symptoms and management of
TAKE HOME MESSAGE the rate of
pericardial effusion depends on
accumulation of effusion
• Elective pericardiocentesis is not warranted in
all pericardial effusions
• Cardiac tamponade is a medical emergency, and
if untreated, its rapidly and universally fatal
• Prompt diagnosis and treatment is the key.
• Pericardiocentesis is a life saving procedure in
tamponade
• Monitor vitals after the procedure to look for