RECOGNITION AND ASSESSMENT
Patients at risk
- Recent cardiac surgery
- Diagnosis of malignancy
- Following myocardial infarction
- Chest trauma
Symptoms and signs
- Dyspnoea
- Decreased conscious level
- Right heart failure (if tamponade chronic)
- Hypotension (systolic BP <100 mmHg)
- Systolic BP falls by >10 mmHg during inspiration
- Raised jugular venous pressure (JVP)
- Rise in JVP with inspiration (it normally falls with inspiration)
- Soft heart sounds
- Heart rate >80 beats/min
- Oliguria or anuria
Investigations
- U&E
- Chest X-ray
- ECG
- Echocardiogram
Life-threatening features
- Severe symptoms
- Signs of shock (tachycardia >100 beats/min, BP <100 mmHg) with marked hypotension during inspiration
- Large effusion on chest X-ray and/or echocardiogram, with evidence of right ventricular (RV) diastolic collapse on echocardiogram
IMMEDIATE TREATMENT
- If life-threatening features are present, contact cardiology team to arrange immediate echocardiography to confirm diagnosis:
- if effusion confirmed, cardiology team will arrange immediate aspiration
- a pericardial drain can be left in situ for several days to facilitate drainage of a large effusion
- If features of effusion present without life-threatening features, contact cardiology team to arrange echocardiography within 24 hr to confirm diagnosis:
- if echocardiogram suggests effusion is large, pericardial aspiration for diagnostic purposes can be carried out safely
- Ensure pericardial fluid sent for biochemical (protein, glucose, LDH), microbiological (MC+S, mycobacterial culture, differential cell count) and cytological investigation, to aid diagnosis
SUBSEQUENT MANAGEMENT
- Consider possible causes of pericardial effusion and refer to cardiology and other appropriate specialities (e.g. renal/haematology)
- Arrange appropriate further investigations (seek specialist advice if necessary) for:
- malignant disease
- acute pericarditis
- chronic renal failure
- connective tissue disease
- cardiac rupture complicating myocardial infarction, trauma or cardiac catheterisation
- recent cardiac surgery
- extension of aortic dissection
- If effusion recurs, contact cardiology team to consider instillation of chemotherapeutic agents into pericardial space or creation of percutaneous or surgical pericardial window
MONITORING TREATMENT
- Temperature, pulse, BP and urine output hourly if shocked, decreasing to 4-hrly and then twice daily in stable patients
DISCHARGE AND FOLLOW-UP
- When haemodynamically stable and effusion tapped, remove aspirating needle or drain
- Follow-up and further treatment depends on underlying diagnosis
© 2022 The Bedside Clinical Guidelines Partnership.
Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.
Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa