II. Definition
- Fluid collection around heart within pericardial sac
III. Causes
- Benign Pericarditis
- Malignant Pericarditis (common, occurs in 20-40% of cancer patients)
- Also occurs as a complication of combination Chemotherapy, Radiation Therapy
- Most common metastatic cancer causes
- Other cancer causes
- Hemopericardium
- Heart surgery from post-operative Hemorrhage (common)
- Myocardial Infarction (free wall ventricular rupture)
- Aortic aneurysm
- Aortic Dissection
- Chest Trauma (especially penetrating Chest Injury)
- Anticoagulation
- Chylopericardium (milky Pericardial Effusion)
- Heart surgery from post-operative lymph collection
- Malignancy (lymphatic obstruction from heart)
IV. Symptoms: Symptoms
- Symptomatic threshold for Pericardial Effusion
- Acute (rapidly progressive): 200 ml
- Chronic: May not be significantly symptomatic until 1-2 Liters are present
- Common Symptoms
- Chest Pain
- Shortness of Breath (especially exertional Dyspnea)
- Palpitations
V. Signs
- See Cardiac Tamponade
-
Pulsus Paradoxus
- Occurs in 77% of Cardiac Tamponade cases
- Beck Triad (more common in rapidly progressive Pericardial Effusions)
- Muffled heart sounds
- Hypotension
- Jugular Venous Distention
VI. Diagnostics: Electrocardiogram
- See Cardiac Tamponade
- Low amplitude wave forms
- Electrical alternans
VII. Imaging: Echocardiogram
- See Echocardiogram
- Features
- Pericardial Effusion will surround the heart and should be seen in multiple views
- Pericardial fluid moves in opposite direction as heart wall
- Cardiac Tamponade
- Right heart wall movement appears as a paradoxical rocking motion
- Right atrium collapse in systole (also occurs with Hypovolemic Shock)
- Right ventricular collapse in diastole
- May appear as a tiny man jumping on right ventricle like a trampoline (PLAX View)
- Size
- Small (<300 ml): <10 mm
- Moderate (500 ml): <10-20 mm
- Large (>700 ml): >20 mm
- Differential diagnosis (look-alikes on Echocardiogram, confirm in multiple views)
- Descending aorta
- Posterior to Pericardium
- Pericardial fat pad
- Fat pad moves with heart wall (in contrast to pericardial fluid)
- Clotted blood may have similar heterogeneous appearance as fat
- However clotted blood moves independently of heart wall
- Pleural Effusions
- Pleural Fluid will stop at descending aorta and not cross the midline
- Pericardial fluid will be circumferential around the heart
- Descending aorta
- Precautions
- Even a small Pericardial Effusion (0.5 cm) can cause tamponade
- References
- Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete's Beach
- Orman, Dawson and Mallin in Majoewsky (2013) EM:Rap 13(1): 4-6
VIII. Management
- Consult cardiothoracic surgery
- Emergent management for Cardiac Tamponade
- Chronic management
- Pericardial window
- Pericardiocentesis with indwelling pericardial catheter drainage
- Malignant Pericardial Effusion
- Consult oncology, Palliative Care when appropriate
- Specific cause management (e.g. Chemotherapy)
- Chemical sclerosis for recurrent malignancy related effusion (by intervention cardiology or thoracic surgery)
- Sclerosing agent (e.g. Bleomycin, Doxycycline) instilled into pericardial space to induce inflammation and fibrosis
- Obliterates pericardial space, preventing reaccumulation of pericardial fluid
IX. Prognosis
- Malignant Pericardial Effusion
- Median survival: 2-4 months
X. References
- Bierowski and Nyalakonda (2025) Crit Dec Emerg Med 39(6): 4-21
- Long, Long and Koyfman (2020) Crit Dec Emerg Med 34(11): 17-24
- Higdon (2018) Am Fam Physician 97(11):741-8 [PubMed]