Echocardiography is the imaging modality of choice for the diagnosis of pericardial effusion, as the test can be performed rapidly and in unstable patients.

https://emedicine.medscape.com/article/157325-workup

Thank you . It’s realily helpfull

Agree that echocardiography is helpful for rapid diagnosis, but even more rapid is blood pressure. When patient is in tamponade the pulse pressure, difference between systolic and diastolic pressure becomes very narrow. A low pulse pressure such as 10 mmHg would be consistent with tamponade. Furthermore, jugular veins will be distended, and heart sounds distant or muffled. Thus diagnosis can be made at bedside. Echocardiography is useful to guide pericardiocentesis, removing fluid from the pericardial sack.

that Means you recommend clinical aspects for diagnosing tamponade . Ultrasound to guide for pericardiocentesis

Caution regarding reliance on TTE or TEE in the postop cardiac surgical patient. In that setting, images may be confounded by chest tubes, etc. Early postop, if there is convergence of PA diastolic pressure and CVP particularly in the setting of moderate or high chest tube output concerning for bleeding, hypotension with or without narrow pulse pressure, and/or rising inotrope requirements -> clinical judgement trumps an equivocal or even negative echo. For this type of scenario it is safer to commit to urgent reexploration rather than have hemodynamic collapse and CPR.

Ofcourse gold standard is by echo, but clinical assessment sudden drop in heart rate, low blood pressure with pulse pressure drop, distended jugular vein and sharp pain in the chest, murmur in apical and sternal area are indicators that will guide for clinical diagnosis. If patient is in high acute areaCVP, PA pressure analysis and ecg will have tailtell signs.

Better explanation , these answers properly addressed my query .

Thank you !

When skiascopy is available , for example in EP, implant. lab or PCI lab. , you can see very well sign of cardiac tamponade (when patient is hypotensive with distended jugular veins ... etc..), because the cardiac siluette completely stops moving during cardiac cycle. It´s very useful sign. First, watch repeatedly normal behavour of the siluette in several patients.

However, I hope that you will never see that sign during any of your procedures .....

Depending upon clinical presentation, acute accumulation of even 100ml of pericardial fluid causes temponade, results in clinical becks triad of raised jvp, hypotension nd muffled heart sounds. x ray chest shows bottle shaped heart and ecg shows low voltage complexes with electrical alterans. after high degree of clinical suspicion, confirm the diagnosis by echocardiography

Whereas chronic accumulation of fluid rarely results in temponade

Dear Muhammad, clinical signs of hypotension, pulsus paradoxus are not always present in cardiac tamponade. ECHO is needed if thus entity is sysoected. Early ECHO signs are: 1)Peak MV/TV E wave respiratory variation (>25%/40% respectively) 2)

Not collapsing of dilated IVC.

Appreciated

@Andrei G Dan .

Sir , this makes Me confuse since this energency case , so what would be best to Diagonise this case Either clinician examiantion or transthoracic Echo.

Now I got reply RHat we need to do both

Hi Muhammad,,, echocardiography is the gold standard to diagnose cardiac tamponade and it helps a lot to guide in pericardiocentesis. In pericardial tamponade you will get RA and /or RV collapse. Then coming to clinical part when you are getting hypotension, pulses paradoxes along with echocardiographic tamponade, that is a grave emergency and urgent pericardiocentesis to be done to save life. But on the other side you can get may patient where echocardiography showed pericardial effusion with features of cardiac tamponade but clinically patients are stable without hypotension or pulses paradoxus, that may not be an emergency..but that group of patients to be monitored closely. So echocardiographic cardiac tamponade along with clinical tamponade is an emergency and that needs urgent pericardiocentesis... Thanks

Hi Muhammad,,, continuing the discussion clinical signs, background and high degree of suspicion is very important to diagnose cardiac tamponade. But echocardiography is the investigation of choice to diagnose cardiac tamponade. But it is very dangerous to give needle in pericardial space on clinical basis without echocardiographic evidence of pericardial effusion or tamponade... Thanks..

THANK you sir Biswajit Majumder .

You r right needle insertion is dangerous without having idea of where the blood is dumpeD .

echo is used to confirm diagnosis whether clinical signs exists or not

As a very old cardiologist (92) from the times when there were not available modern diagnostic auxiliaries, I was learned that the main sign of such an emergency situation was engorgement of jugular veins together with sudden deterioration of general state ( a sitting, to the anterior inclined dyspnoic and tachypnoic patient with tachycardia, pulsus paradoxus and a drop of blood pressure), and that the definitive proof is a blood in a punctate of the pericardium).

Today it is much easier and more comfortable to diagnose such a situation, but it should be kept in mind that even today there are situations without availability of ultrasound etc. when the diagnosis depends only of the physicians skill.

So, do not never forget that the strength of the art of clinical diagnosis is unsurpassed.

@Aleksandar Nedok

Thank you sir for sharing the Worthy experience here . your words mean more to me .

Cardiac tamponade is a clinical diagnosis. Best test is careful clinical examination: low BP, paradoxical pulse and right sided signs, specially jugular venous distension make the diagnosis.

Echocardiogram may miss clinically significant tamponade.

Pressure wave measurements are invasive

and you generally need to decide fast....

The best initiol test for cardiac tamponede is clinical examination, Ehoc., and primarly Jugular Doppler floumetry - small, unphased modality and slight respiratory changes of velocity pattern.

Cardiac tamponade results from an accumulation of pericardial fluid under pressure, leading to impaired cardiac filling and haemodynamic compromise. Prompt diagnosis is the key to reducing the mortality risk for patients with cardiac tamponade. Although cardiac tamponade is a clinical diagnosis, echocardiography provides useful information and is the cornerstone during evaluation (availability, bedside, and treatment). However, cardiac tamponade is associated with a variety of abnormalities that lead to changes on the electrocardiogram (ECG), chest X-ray, and on echocardiography. Abnormalities of tamponade on the ECG are typically low voltage and electrical alternans. However, reduced voltage can also be seen among other conditions such as infiltrative myocardial disease and emphysema, whereas electrical alternans characterised by beat to beat alterations in the QRS complex caused by swinging of the heart is specific, but not sensitive for tamponade. The chest X-ray reveals a normal cardiac silhouette until the effusions are at least moderate in size (~200 mL). In general, an enlarged cardiac silhouette is neither sensitive nor specific for the diagnosis of cardiac tamponade.

Echocardiographic techniques remain the standard non-invasive method to establish the diagnosis and can be used to visualise ventricular and atrial compression abnormalities as blood cycles through the heart.An effusion appears as a transparent separation between the parietal and visceral pericardium during the cardiac cycle. Physiologic pericardial fluid may only be visible during ventricular systole, whereas effusions exceeding 75-100 mL are visualised throughout the cardiac cycle

References

1. Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A.; European Society of Cardiology (ESC). 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7;36(42):2921-64.

2. Ben-Horin S, Shinfeld A, Kachel E, Chetrit A, Livneh A. The composition of normal pericardial fluid and its implications for diagnosing pericardial effusions. Am J Med. 2005 Jun;118(6):636-40.

@Entedhar sarhat

Thank you so much

A screening ECHO is always the best. Clinical signs such as pulsus paradoxus aren't so reliable. If you have an arterial line in place, you may often huge "swings" in the waveforms on the monitor. Your ECG may show low voltages of the QRS complexes.

Tamponade is a clinical emergency that requires a high index of suspicion to diagnose. Echo is the gold standard for diagnosis as descibed by colleagues.