Cardiac tamponade

First steps

1. Suspect it in the dyspneic, tachycardic patient with a raised JVP, especially with cancer, a recent cardiac procedure, or chest trauma.^1,4,8
2. Bedside echo now. Look for an effusion, then for right atrial and right ventricular collapse and a plethoric IVC.^3,5
3. Check pulsus paradoxus if the patient is stable enough. Over 10 mm Hg supports tamponade.⁴
4. Decide needle or surgeon. Type A aortic dissection, free wall rupture after MI, severe chest trauma and uncontrolled procedural bleeding go to surgery.^2,3
5. Keep preload up. Avoid intubation and sedation if you can. Give gentle fluid to the hypotensive, dry patient. Give blood for traumatic hemopericardium. Correct anticoagulation and coagulopathy.³
6. Drain it. Emergently for instability, deterioration or arrest. Otherwise, use the ESC triage score to time it.^1,3

Recognize

Fluid in the pericardium compresses the cardiac chambers. How sick the patient gets depends on how much fluid there is, how fast it gathered, and how stretchy the pericardium is.¹ Dehydration, vasodilators and IV diuretics can tip an existing effusion into tamponade.²

Sensitivities come from a systematic review of 8 studies of patients with known effusions or tamponade.⁴ The ECG data come from 241 patients with moderate or large effusions, 66 of whom had tamponade.⁶

Pulsus paradoxus is a drop in systolic pressure of 10 mm Hg or more on inspiration during normal breathing. It also occurs in acute asthma, massive pulmonary embolism, constrictive pericarditis and hypovolemia.¹⁰

Bedside echo

Effusion size by the ESC, measured as the largest echo-free space between the heart and the pericardium at end-diastole.¹ A large effusion (over 20 mm) is a high-risk feature in pericarditis.¹

• Emergency physicians can find the fluid. In 515 high-risk ED patients, emergency physician echo detected effusions with 96% sensitivity and 98% specificity against cardiology review.⁵
• Diastolic right ventricular collapse is the specific sign. Systolic right atrial collapse and a plethoric, non-collapsing IVC are the sensitive ones.³
• Sonographic pulsus paradoxus is another sign.³
• No sign is universal. In 239 ED patients drained within 48 hours, 69.1% had RV diastolic collapse, 62.3% had exaggerated mitral inflow variation, 56.4% had a plethoric IVC, and 53.4% had RA systolic collapse.¹¹

ESC triage score

The ESC uses a triage score, built by expert consensus, to decide whether to drain at once or delay.^1,9 Hemodynamic instability, impending deterioration or cardiac arrest call for emergent drainage.³

Restated from the 2025 ESC guideline (Figure 12), which adopted the 2014 position statement of its working group.^1,9 The guideline's text and caption say more than 6 points from at least two categories means urgent drainage. Its flowchart box says 6 or more. Below that, the flowchart postpones drainage and starts empiric anti-inflammatory therapy. After drainage, patients who improve go to outpatient follow-up, and those who don't get a pericardial window.¹

Before the needle

• Avoid positive-pressure ventilation and IV sedation if you can. Both can lower cardiac output.³
• Fluid is a bridge, not a treatment. In 49 patients with hemodynamic tamponade given 500 mL saline over 10 minutes, cardiac index rose by more than 10% in 47%, was unchanged in 22%, and fell in 31%. A systolic pressure under 100 mm Hg predicted a good response.⁷
• Give blood for traumatic hemopericardium. Treat anticoagulation, coagulopathy and anemia.³
• Consider vasoactive drugs in hypotensive patients, alongside gentle fluids.³ Drainage is the treatment.²

Drainage

• Pericardiocentesis (echo-, CT- or fluoroscopy-guided) is recommended for tamponade, suspected bacterial or cancer-related pericarditis, and symptomatic moderate to large effusions despite medical therapy (Class I, level C).¹
• Echo guidance works. In 1,127 echo-guided pericardiocenteses at one center, the success rate was 97%. Complications occurred in 4.7% (major 1.2%).⁸
• Technique: a 16–20 gauge needle, usually from below the xiphoid; an apical or left lateral approach is possible. Pick the largest, shallowest pocket with nothing vital in the way.^1,3
• Confirm the needle is in the pericardium with agitated saline and a look at the first aspirate for blood.³
• Drain slowly. Take usually under 500 mL at first to avoid pericardial decompression syndrome. Leave a drain in until output falls under 30 mL a day.^1,3

Causes

• Common, most frequent first: cancer, procedures and trauma, pericarditis, and tuberculosis (the most common cause in low-income countries).¹
• Less common: autoimmune disease, pericardial injury syndromes, acute MI, aortic dissection, uremia, bacterial infection, and pneumopericardium.¹
• Procedures are now a leading cause. In the Mayo Clinic series, cardiac surgery, cancer and catheter-procedure perforations together made up nearly 70% of drainages.⁸
• Acute pericarditis rarely causes tamponade: under 1% of cases.¹

Disposition

• Tamponade: admit. Signs of tamponade and a large effusion are high-risk features in the ESC pericarditis risk table, and the ESC recommends admitting high-risk patients.¹
• Effusion without tamponade: the ESC score helps decide whether drainage can be delayed.¹ Drainage is also indicated when the cause must be found, as in suspected cancer or bacterial infection.¹
• After drainage: NSAIDs and colchicine can be considered to prevent recurrence.²

References

1. 1
   Schulz-Menger J, Collini V, Gröschel J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J. 2025;46(40):3952–4041.GuidelinePMID 40878297DOIFull text read
2. 2
   Adler Y, Ristić AD, Imazio M, et al. Cardiac tamponade. Nat Rev Dis Primers. 2023;9(1):36.ReviewPMID 37474539PubMed
3. 3
   Alerhand S, Adrian RJ, Long B, Avila J. Pericardial tamponade: a comprehensive emergency medicine and echocardiography review. Am J Emerg Med. 2022;58:159–174.ReviewPMID 35696801PubMed
4. 4
   Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does this patient with a pericardial effusion have cardiac tamponade? JAMA. 2007;297(16):1810–1818.Meta-analysisPMID 17456823PubMed
5. 5
   Mandavia DP, Hoffner RJ, Mahaney K, Henderson SO. Bedside echocardiography by emergency physicians. Ann Emerg Med. 2001;38(4):377–382.Diagnostic studyPMID 11574793PubMed
6. 6
   Mathur AP, Saini A, Lucas BP, et al. Diagnostic accuracy retrospectively of electrocardiographic findings and cancer history for tamponade in patients determined to have pericardial effusion by transthoracic echocardiogram. Am J Cardiol. 2013;111(7):1062–1066.Diagnostic studyPMID 23351462PubMed
7. 7
   Sagristà-Sauleda J, Angel J, Sambola A, Permanyer-Miralda G. Hemodynamic effects of volume expansion in patients with cardiac tamponade. Circulation. 2008;117(12):1545–1549.CohortPMID 18332261PubMed
8. 8
   Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77(5):429–436.CohortPMID 12004992PubMed
9. 9
   Ristić AD, Imazio M, Adler Y, et al. Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2014;35(34):2279–2284.ConsensusPMID 25002749PubMed record; full text not openly accessible
10. 10
    Life in the Fast Lane. Pulsus paradoxus.FOAMlitfl.comPage read
11. 11
    Eke OF, Jalbout NA, Selame L, et al. Pericardial tamponade: a new perspective on echocardiographic features and application of a prediction score. Intern Emerg Med. 2024;19(6):1757–1764.CohortPMID 38907757PubMed