Does This Patient Have Pericardial Effusion?

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Emergency department diagnosis of pericardial effusion is critical. The presence of a pericardial effusion may be suggested on history and physical examination. Transthoracic echocardiography is recommended in patients with suspected pericardial effusion. However, the indications for an emergent echocardiogram based on clinical findings are not clearly defined. The purpose of this study was to investigate the presenting clinical features of patients with pericardial effusion to determine the need for an emergent bedside ultrasound examination. A retrospective review of all point-of care cardiac ultrasound examinations performed at two urban academic emergency departments. The point-of-care ultrasound examinations were reviewed for the presence of a pericardial effusion by an emergency physician with advanced training in bedside US. Medical records were then reviewed for history and physical exam findings suggestive of pericardial effusion. Descriptive statistics are presented along with 95% confidence intervals (CI). A total of 814 POC cardiac US examinations were reviewed. Fifty pericardial effusions were identified for an estimated prevalence of 6.1%. Three patients were excluded from the analysis because of lack of appropriate documentation. Sixteen patients had a moderate to large pericardial effusion. Five patients required emergent pericardiocentesis. The presenting symptoms of patients with pericardial effusions were: shortness of breath (65.2%), chest pain (34.7%), syncope (10.8%) and altered mental status (10.8%). Tachycardia or hypotension was present in 72.3% of patients. None of the patients with pericardial tamponade were found to have Beck's triad. Sensitivity of Beck's triad for pericardial tamponade was therefore 0% (95% CI, 0, 7.5%). Sensitivity for one finding of Beck's triad was 55% (95% CI, 40.1, 69.8). Despite limited numbers, our study illustrates the limitations of clinical criteria in determining the need for an echocardiogram in diagnosing a pericardial effusion and supports liberal use of bedside ultrasound when evaluating patients with shortness of breath and chest pain.