PE, tamponade and aortic emergencies

Cardiac tamponade and pericardiocentesis

Reviewed Nov 2026·2 references
New· views rounded down, updated weekly

Clinical and echo diagnosis of tamponade, temporising measures, and urgent drainage.

Definition
Cardiac tamponade = life-threatening compression of the heart by pericardial fluid, pus, blood, clot or gas, causing impaired filling and obstructive shock. It is a clinical and echocardiographic diagnosis; the rate of accumulation matters more than volume.

At the bedside

  1. 1

    Suspect

    Hypotension, tachycardia, raised JVP, muffled heart sounds (Beck triad), pulsus paradoxus > 10 mmHg, low-voltage ECG/electrical alternans. Contexts: malignancy, TB, uraemia, post-cardiac surgery/procedure, trauma, aortic dissection, hypothyroidism.

  2. 2

    Echo

    < 10 min

    Circumferential effusion with RA systolic collapse, RV diastolic collapse, dilated IVC with < 50% collapse, exaggerated respiratory variation in mitral (> 25%) and tricuspid (> 40%) inflow.

  3. 3

    Temporise

    Small fluid bolus (250-500 mL) may help if hypovolaemic; vasopressor/inotrope as bridge; avoid intubation and positive-pressure ventilation if possible (can precipitate arrest) - if unavoidable, drain first or have the needle ready.

  4. 4

    Drain urgently

    ASAP

    Echo-guided pericardiocentesis (subxiphoid or apical/parasternal, where fluid is closest) with pigtail catheter; or surgical drainage for purulent, clotted, loculated, post-surgical or traumatic effusions.

  5. 5

    Do NOT needle in aortic dissection

    Tamponade from type A dissection or myocardial rupture needs emergency surgery; pericardiocentesis can worsen bleeding (only controlled small-volume drainage as last resort).

  6. 6

    Send fluid and find the cause

    Cell count, protein, LDH, glucose, Gram stain, culture, AFB/GeneXpert, ADA (TB), cytology. Leave drain until < 25-50 mL/day.

Echo signs of tamponade

SignSignificance
RA collapse > 1/3 of systoleSensitive, early
RV diastolic collapseMore specific
Plethoric IVC (> 2.1 cm, < 50% collapse)Sensitive; absent in hypovolaemia ('low-pressure tamponade')
Mitral inflow variation > 25%Doppler equivalent of pulsus paradoxus
Swinging heartLarge effusion, electrical alternans
Red flag · call your senior now
Effusion + hypotension + plethoric IVC = drain now; prepare for arrest.
Red flag
Post-cardiac surgery tamponade may be localised (clot behind the RA/LV) and missed on transthoracic echo; re-sternotomy may be needed.
Pitfall
Intubating before drainage: loss of sympathetic tone and positive pressure collapse filling.
Pitfall
Ruling out tamponade because effusion is 'small': rapid accumulation of 100-200 mL can tamponade.
Pearl
TB is the commonest cause of large pericardial effusion in India; send ADA and GeneXpert from pericardial fluid.
Pearl
Low-pressure tamponade occurs in hypovolaemia (dialysis, bleeding): JVP may not be raised; a fluid bolus helps.

References

  1. 1

    Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J 2015;36:2921-64.

  2. 2

    Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation 2022;146:e334-482.

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