Emergency Medicine · Year 3 · from Emergency Medicine

Case 3: Cardiac Tamponade

Patient Demographics

  • Age: 45 years
  • Sex: Male
  • Occupation: Sales representative

Chief Complaint

"I can't catch my breath and I feel like I'm going to die."

History of Present Illness

A 45-year-old male presents with 3 days of progressive dyspnea and chest discomfort. He had a "viral illness" 2 weeks ago with fever, body aches, and sore throat that resolved. Over the past few days, he developed worsening shortness of breath, especially when lying flat, and a dull chest ache. Today he feels extremely weak and nearly passed out at home.

Initial Assessment

ESI Level: 1 - Critical, hemodynamically unstable

Vital Signs:

  • Heart rate: 122 bpm
  • Blood pressure: 82/64 mmHg
  • Respiratory rate: 28 breaths/min
  • SpO2: 92% on room air
  • Pulsus paradoxus: 22 mmHg

Physical Examination

Beck's Triad Present:

  1. Hypotension (SBP 82)
  2. Jugular venous distension (JVP to angle of jaw)
  3. Muffled heart sounds

Additional Findings:

  • Tachypnea, using accessory muscles
  • Clear lung fields (no pulmonary edema)
  • Cool extremities, weak pulses
  • No peripheral edema

Diagnostic Evaluation

ECG:

  • Sinus tachycardia
  • Low voltage QRS complexes
  • Electrical alternans (alternating QRS amplitude)

Chest X-ray:

  • Enlarged cardiac silhouette ("water bottle" configuration)
  • Clear lung fields

Bedside Echocardiography:

  • Large circumferential pericardial effusion
  • Right atrial collapse during late diastole
  • Right ventricular diastolic collapse
  • IVC plethora (>2.1cm, <50% collapse)
  • Swinging heart motion

Diagnosis

Cardiac Tamponade secondary to viral pericarditis (presumed)

Management

Immediate Stabilization:

  1. IV fluid bolus (500mL) - transient improvement
  2. Avoid positive pressure ventilation if possible
  3. Prepare for emergent pericardiocentesis
  4. Cardiothoracic surgery on standby

Pericardiocentesis:

  • Subxiphoid approach under ultrasound guidance
  • 18-gauge needle advanced at 45-degree angle toward left shoulder
  • 650mL of serosanguinous fluid aspirated
  • Pigtail drain left in place

Immediate Response:

  • BP improved to 112/74 mmHg
  • HR decreased to 92 bpm
  • JVD resolved
  • Marked symptomatic improvement

Pericardial Fluid Analysis

  • Appearance: Serosanguinous
  • WBC: 2,400/mm3 (lymphocyte predominant)
  • Protein: 4.2 g/dL (exudate)
  • Glucose: 68 mg/dL
  • LDH: 380 U/L
  • Cytology: Negative for malignancy
  • Cultures: No growth

Hospital Course

  • Drain output decreased over 3 days
  • Drain removed day 4
  • Started on colchicine 0.5mg BID and ibuprofen 600mg TID
  • Echo prior to discharge: Small residual effusion, no tamponade physiology
  • Discharged day 5

Final Diagnosis

Cardiac tamponade secondary to viral (idiopathic) pericarditis

Teaching Points

  1. Beck's triad: Classic but not always complete - JVD, muffled heart sounds, hypotension
  2. Pulsus paradoxus >10mmHg: Highly suggestive of tamponade physiology
  3. Electrical alternans: Pathognomonic ECG finding due to swinging heart
  4. Bedside echo is diagnostic: Right chamber collapse, IVC plethora
  5. Avoid positive pressure ventilation: Worsens venous return and hemodynamics
  6. Pericardiocentesis is life-saving: Even small volume removal dramatically improves hemodynamics

Clinical Image

Image Description: Echocardiogram (parasternal long axis view) demonstrating a large circumferential pericardial effusion with right ventricular diastolic collapse, consistent with cardiac tamponade.

Attribution: Image from Wikimedia Commons, Echocardiogram showing pericardial effusion. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Pericardial_effusion_with_tamponade.jpg

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