Cardiac Tamponade

Patient Presentation:
M.B., a 34 y/o female, presents to the ED with anxiety, palpitations, and chest pain.  She was recently diagnosed with breast cancer, is s/p lumpectomy and is currently receiving radiation to the chest.  Pt denies fever, chills, SOB, cough, abdominal pain, or N/V/D.  Pt also denies alcohol, smoking, and illicit drug use.

VS & ROS:
T 98.9, BP  90/60, HR 100, RR 26, SpO2 98% RA
Neuro:  AAOx3
Lungs: CTAB. Tachypneic.
Heart:  S1, S2, distant and faint with rub present.  Tachycardic but with Regular Rhythm. JVD present.
Abd:  soft, non-tender, non-distended.  BS (bowel sounds) present.
Ext:  Peripheral pulses weak bilaterally.

Differential List:
MI, PE, hypovolemia, cardiac tamponade,

Tests & Diagnosis:
EKG shows decreased voltage.
Chest x-ray shows increased cardiac silhouette.
Echocardiogram is positive for pericardial effusion.

Diagnosis = Cardiac Tamponade

Treatment:
Pericardiocentesis is the usual treatment for cardiac tamponade unless there is an aortic or myocardial rupture in which case surgery is more appropriate.  This case was treated with pericardiocentesis.

Outcome:
M.B. underwent a pericardiocentesis (needle inserted to remove fluid from pericardial sac) and was admitted to the ICU.  Her condition resolved and she was eventually discharged home.  Radiation to her chest was the most likely etiology.

Summary:
Cardiac Tamponade is a medical emergency that requires prompt attention.
Any cause of pericarditis can cause tamponade but especially malignancy, uremia, or idiopathic. Rapidly accumulating effusions result in tamponade.
Pt can present in cardiogenic shock (hypotension, fatigue) without pulmonary edema.  Dyspnea is also seen in about 85% of cases.
Physical exam will reveal distant heart sounds, JVD, and hypotension.  May also see tachycardia and cool extremities.  Pulsus paradoxus is a common finding.  Pericardial friction rub may be auscultated and tachypnea will be present but with clear lungs.
Treatment includes volume (be careful! overfilling can worsen tamponade) and positive inotropes (avoid beta-blockers).  Treatment is pericardiocentesis or surgery (pericardial window - cuts part of the pericardium and allows fluid to drain into abdomen).
Case created by Mimi Balaji, 2011.