Patients at risk

• Recent cardiac surgery
• Diagnosis of malignancy
• Following myocardial infarction
• Chest trauma

Symptoms and signs

• Dyspnoea
• Decreased conscious level
• Right heart failure (if tamponade chronic)
• Hypotension (systolic BP <100 mmHg)
• Systolic BP falls by >10 mmHg during inspiration
• Raised jugular venous pressure (JVP)
• Rise in JVP with inspiration (it normally falls with inspiration)
• Soft heart sounds
• Heart rate >80 beats/min
• Oliguria or anuria

Investigations

• U&E
• Chest X-ray
• ECG
• Echocardiogram

Life-threatening features

• Severe symptoms
• Signs of shock (tachycardia >100 beats/min, BP <100 mmHg) with marked hypotension during inspiration
• Large effusion on chest X-ray and/or echocardiogram, with evidence of right ventricular (RV) diastolic collapse on echocardiogram

• If life-threatening features are present, contact cardiology team to arrange immediate echocardiography to confirm diagnosis:
• if effusion confirmed, cardiology team will arrange immediate aspiration
• a pericardial drain can be left in situ for several days to facilitate drainage of a large effusion
• If features of effusion present without life-threatening features, contact cardiology team to arrange echocardiography within 24 hr to confirm diagnosis:
• if echocardiogram suggests effusion is large, pericardial aspiration for diagnostic purposes can be carried out safely
• Ensure pericardial fluid sent for biochemical (protein, glucose, LDH), microbiological (MC&S, mycobacterial culture, differential cell count) and cytological investigation, to aid diagnosis

• Consider possible causes of pericardial effusion and refer to cardiology and other appropriate specialities (e.g. renal/haematology)
• Arrange appropriate further investigations (seek specialist advice if necessary) for:
• malignant disease
• acute pericarditis
• chronic renal failure
• connective tissue disease
• cardiac rupture complicating myocardial infarction, trauma or cardiac catheterisation
• recent cardiac surgery
• extension of aortic dissection
• If effusion recurs, contact cardiology team to consider instillation of chemotherapeutic agents into pericardial space or creation of percutaneous or surgical pericardial window

• Temperature, pulse, BP and urine output hourly if shocked, decreasing to 4-hrly and then twice daily in stable patients

• When haemodynamically stable and effusion tapped, remove aspirating needle or drain
• Follow-up and further treatment depends on underlying diagnosis