Cardiac Tamponade

Roy CL et al. Does This Patient With a Pericardial Effusion Have Cardiac
Tamponade? JAMA. 2007;297:1810-8.

Cardiac tamponade: Clinical state where pericardial fluid compresses the heart and
compromises cardiac output

Echocardiography findings:
• RA systolic collapse
• RV diastolic collapse
• IVC plethora
• Exaggeration of respirophasic changes in flow velocities across TV and MV

Normal pericardial fluid volume = 15-30 mL

Systematic review of 8 studies with a total of 300 patients:

Sensitivity Specificity + LR - LR
Clinical history
• Dyspnea 87-88%
Physical exam
• Tachycardia 77%
• Hypotension 26%
• Diminished heart sounds 28%
• Elevated JVP 76%
EKG
• Low voltage 42%
• Electrical alternanas 16-21%
• ST elevation 18-30%
• PR depression 18%
CXR – Cardiomegaly 89%
Pulsus Paradoxus
>12 mm Hg 98% 83% 5.9 0.03
>10 mm Hg 98% 70% 3.3 0.03

Pulsus paradoxus phenomenon:

• During inspiration, the negative intrapleural pressure increases venous return to the
heart and increases RV filling. The ventricular septum bows to the left, decreasing
LV filling. Thus, the SBP drops slightly with inspiration.
• In cardiac tamponade, the restrictive pericardial fluid exaggerates the RV filling and
compromises LV filling more. This drops the SBP more dramatically with inspiration.

How to measure pulsus paradoxus:

• Using a manual BP cuff, listen to the brachial artery.
• Inflate the cuff so that no arterial sounds are heard.
• Release the cuff pressure slowly until faintest, intermittent Korotkoff arterial sounds
are heard - typically in expiration phase only. Remember this pressure (A).
• Release the cuff pressure further until arterial sounds are heard throughout
inspiration and expiration phases. Remember this pressure (B).
• Pulsus paradoxus = A – B.

Pulsus paradoxus may help guide decision for pericardiocentesis with equivocal or
unavailable echo U/S. If >12 mm Hg, this demonstrates physiologic compromise.