eMedicine Specialties > Emergency Medicine > Cardiovascular

Pericarditis and Cardiac Tamponade: Differential Diagnoses & Workup

Author: Verena T Valley, MD, Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital
Coauthor(s): Christopher A Fly, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia
Contributor Information and Disclosures

Updated: May 12, 2008

Differential Diagnoses

Dissection, Aortic

Other Problems to Be Considered

Liver disease has been noted in asymptomatic constrictive pericarditis.

Workup

Laboratory Studies

  • CBC count with differential
  • Elevated erythrocyte sedimentation rate (ESR)
  • Creatine kinase and isoenzymes levels - Troponin I may be elevated in viral or idiopathic acute pericarditis.
  • Elevated lactate dehydrogenase and serum glutamic-oxaloacetic transaminase levels
  • Human immunodeficiency virus (HIV) testing
  • Tuberculosis skin testing
  • Thyroid function testing
  • Antinuclear antibody, rheumatoid factor testing

Imaging Studies

  • Chest radiography
    • This is not helpful in uncomplicated viral pericarditis. A water bottle–shaped heart can be seen with excessive pericardial fluid accumulation.
    • In cardiac tamponade (or large effusions), the chest radiograph may reveal an enlarged cardiac silhouette after 200-250 mL of fluid accumulation. This occurs in patients with slow fluid accumulation, compared with a normal cardiac silhouette seen in patients with rapid accumulation and tamponade. Thus, the chronicity of the effusion may be suggested by the presence of a huge cardiac silhouette.
  • Limited echocardiography
    • In pericarditis, the pericardium may have a normal appearance, without evidence of fluid accumulation.
    • Echocardiographers use M-mode to evaluate pericardial fluid and timing during the cardiac cycle.
    • Emergency sonographers essentially note the presence or absence of pericardial fluid, may comment on the amount of fluid, and/or note right ventricular collapse.
    • Very small effusions are located posterior and inferior to the left ventricle.
    • Moderate effusions extend toward the apex of the heart, and large effusions circumscribe the heart. Weitzman criteria define a moderate effusion as an echo-free pericardial space (anterior plus posterior) of 10-20 mm during diastole and a large effusion as an echo-free space more than 20 mm.
    • The emergency sonographer may encounter difficulty using the classic textbook sonographic findings of tamponade, as the trauma patient is often tachycardic and the examination abbreviated.
    • A swinging heart may be present. This is characterized as counterclockwise rotational movement, which occurs in addition to the triangular movement of the heart, producing a dancelike motion.
    • A dilated inferior vena cava (IVC) without inspiratory collapse (plethora) is highly suggestive of tamponade.
  • Transthoracic echocardiography: This is limited in its capacity to reveal the entire pericardium and its operator dependence, although it remains the initial test of choice for detecting pericardial effusions and diagnosing tamponade.
  • CT scanning
    • CT scanning provides anatomic details of the entire pericardium due to its capacity in providing a wide field of view. CT scanning is less operator dependent. The normal thickness of the pericardium as measured by CT scanning is less than 2 mm.
    • An advantage of CT scanning over other imaging modalities includes its capacity to detect pericardial calcifications. MRI can miss significant calcium deposits. The presence of any calcification is important in patients suspected of having constrictive pericarditis.
    • Limitations of CT scanning include the need for contrast administration, patient exposure to ionizing radiation, and difficulty in differentiating fluid from thickened pericardium.
  • MRI
    • MRI can provide anatomic details of the pericardium and heart without ionizing contrast or radiation. The normal pericardium can be up to 4-mm thick.
    • Limitations to use of MRI include the need to gate the image acquisition. A high-quality MRI may need more than 250 regular heartbeats. Thus, the examination may be limited in patients with arrhythmias.

Other Tests

  • Electrocardiography
    • Electrical alternans is pathognomonic of cardiac tamponade and is characterized by alternating levels of ECG voltage of the P wave, QRS complex, and T waves. This is a result of the heart swinging in a large effusion.
    • ECG can be diagnostic in acute pericarditis and evolves in 4 stages. Only 50% of patients with pericarditis experience all 4 stages.
      • The first stage is characterized by ST-segment elevation with concave upward ST segments. It can be seen within hours of chest pain and lasts several days. The ST-segment changes usually are noted in all leads except V1.
      • In the second stage, the ST segments return to baseline with T-wave flattening.
      • The third stage is distinguished by T-wave inversion without Q-wave formation.
      • The fourth stage is characterized by ECG normalization.
    • Another important ECG finding is PR-segment depression, which has been reported in up to 80% of viral pericarditis cases.

Procedures

  • Pericardiocentesis
    • The traditional approach is the subxiphoid technique. This technique avoids injury to the coronary arteries.
    • The chest is prepared with Betadine and a 16- to 18-gauge catheter is introduced between the xiphoid and the left subcostal margin.
    • The catheter is directed toward the inferior tip of the left scapula with slow advancement and with negative pressure.
    • If fluid is found, the catheter is advanced and the needle is withdrawn. Fluid is removed via the catheter.
    • The catheter may be sutured in place for subsequent use.
    • Alternatively, a 16- to 18-gauge spinal needle may be used for one-time drainage.
  • Echocardiographically guided pericardiocentesis
    • Echocardiographically guided pericardiocentesis has evolved over the past 20 years and is now considered the procedure of choice for removal of pericardial fluid. The technique for echocardiographically guided pericardiocentesis differs from traditional blind pericardiocentesis primarily in the site of needle entry.
    • The left chest wall has become the preferred location for needle entry under echocardiographic guidance. The intended needle trajectory is investigated with echocardiography to confirm the optimal direction and depth for needle advancement. A 16-gauge needle (with poly-Teflon sheath) is advanced in a straight line without side-to-side manipulation. Needle position can be established via echocardiography while agitated sterile saline is injected.
    • The step-by-step approach for echocardiographically-guided pericardiocentesis is as follows:
      • Assess the size, distribution, and ideal needle entry site and trajectory with a 2.5- to 5-MHz ultrasound transducer placed approximately 3-5 cm from the parasternal border. Locate the point where the effusion is closest to the transducer as well as an area of maximal pericardial fluid accumulation.
      • Assess or measure the distance from the skin to the pericardial space. The needle trajectory is established by the angle of the transducer. Keep this trajectory in mind during the procedure.
      • Use a sterile skin preparation such as povidone-iodine and, if readily available, a transparent sterile plastic sheet (one author recommends a 1030 Baxter drape) to allow imaging and a sterile field.
      • Place a sterile 16-gauge catheter on the predetermined location on the chest wall, avoiding the inferior rib margin. Advance in the predetermined direction, angle, and depth. Advance 2 mm further once fluid is obtained. Consider leaving the catheter in place after removing the needle. If needed, a guidewire can be advanced through the catheter.
  • Central venous pressure measurement
    • If echocardiography is unavailable, placement of a central venous pressure (CVP) line may reveal increased right-sided pressures. CVP measurements more than 12-14 mm Hg are usually found in cardiac tamponade.
    • Thoracotomy and pericardiotomy may be required in the ED if the patient has rapid deterioration or cardiac arrest.

More on Pericarditis and Cardiac Tamponade

Overview: Pericarditis and Cardiac Tamponade
Differential Diagnoses & Workup: Pericarditis and Cardiac Tamponade
Treatment & Medication: Pericarditis and Cardiac Tamponade
Follow-up: Pericarditis and Cardiac Tamponade
Multimedia: Pericarditis and Cardiac Tamponade
References
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Further Reading

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Keywords

pericardium, pericardial complex, acute pericardial tamponade, pericardial effusion, malignancy, tuberculous pericarditis, precordial chest pain, retrosternal chest pain, end-stage renal disease, ESRD, traumatic tamponade, decompressing tamponade, pericardial friction rub, premature atrial contractions, premature ventricular contractions, cardiac arrhythmias, tachypnea, dyspnea, myocarditis, Ewart sign, hepatomegaly, ascites, Beck triad, jugular venous distention, hypotension, muffled heart sounds, pulsus paradoxus, cyanosis, serous pericarditis, rheumatoid arthritis, RA, systemic lupus erythematosus, SLE, fibrous pericarditis, serofibrinous pericarditis, acute myocardial infarction, AMI, Dressler syndrome, uremia, radiation, suppurative pericarditis, purulent pericarditis, cardiotomy, constrictive pericarditis, hemorrhagic pericarditis, bleeding diathesis, caseous pericarditis, adhesive mediastinopericarditis, concretio cordis, malignant pericarditis, penetrating cardiac injuries, hemopericardium, pericardial hematoma, pacemaker insertion, cardiac catheterization, sternal bone marrow biopsies, pericardiocentesis, dermatopolymyositis

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Contributor Information and Disclosures

Author

Verena T Valley, MD, Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital
Verena T Valley, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher A Fly, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia
Christopher A Fly, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

David A Peak, MD, Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary
David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Charles V Pollack, Jr, MD, MA, FACEP, Professor, Department of Emergency Medicine, University of Pennsylvania College of Medicine; Chairman, Department of Emergency Medicine, Pennsylvania Hospital
Charles V Pollack, Jr, MD, MA, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: sanofi-aventis Honoraria Consulting; sanofi-aventis Honoraria Speaking and teaching; Schering-Polugh Honoraria Consulting; Schering-Plough Honoraria Speaking and teaching; The Medicines Company Honoraria Consulting; GlaxoSmithKline Grant/research funds Other

 
 
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