Excerpt from Pericarditis and Cardiac Tamponade

Synonyms, Key Words, and Related Terms: 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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Background

Pericarditis and cardiac tamponade are clinical problems that involve the potential space surrounding the heart or pericardium. Pericarditis is one cause of fluid accumulation in this potential space; cardiac tamponade is the hemodynamic result of fluid accumulation.

The use of limited echocardiography by emergency physicians has enhanced the diagnosis of cardiac tamponade from various causes, including trauma and infectious and noninfectious etiologies.

Pathophysiology

The pericardium (pericardial complex) consists of an outer fibrous layer and an inner serous layer. The fibrous pericardium is a flask-shaped, tough outer sac with attachments to the diaphragm, sternum, and costal cartilage. The serous layer is thin and is adjacent to the surface of the heart. The pericardium serves as a protective barrier from the spread of infection or inflammation from adjacent structures.

The potential space produced by these layers contains approximately 20 mL of fluid with electrolyte and protein profiles similar to plasma. Approximately 120 mL of additional fluid can accumulate in the pericardium without an increase in pressure. Further fluid accumulation can result in marked increases in pericardial pressure, eliciting decreased cardiac output and hypotension (cardiac tamponade). The rapidity of fluid accumulation influences the hemodynamic effect.

Frequency

United States

Malignant disease is the most common cause of pericardial effusion with tamponade. The reported incidence of acute pericardial tamponade is approximately 2% of penetrating trauma. The condition is rarely seen in blunt chest trauma.

International

Although malignancy is the most common etiology of pericardial effusions in developed countries, tuberculosis should be considered in endemic areas.

Mortality/Morbidity

The early diagnosis of significant pericardial and cardiac injuries can prevent morbidity and enhance survival.

Penetrating cardiac injury: Immediate identification of penetrating cardiac injuries via emergency department (ED) echocardiography can improve survival rate and neurologic outcome.
Nontraumatic pericardial effusion: Prompt identification using ED bedside echocardiography streamlines appropriate therapy and disposition.

Sex

Pericarditis is more common in males than in females.

Age

Pericarditis is more common in adolescents and young adults. In one study, Merce et al found no difference in etiology, clinical course, and prognosis between elderly and younger patients with moderate and large pericardial effusions.¹

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