Cardiac tamponade physical examination: Difference between revisions

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Latest revision as of 13:41, 3 February 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Ahmed Zaghw, M.D. [3] Ramyar Ghandriz MD [4]

Overview

Physical examination may vary depending on the type of cardiac tamponade. Physical examination may show the classic Beck's triad (hypotension, muffled heart sound, and elevated jugular venous distension), tachycardia, pulsus paradoxus, and pericardial rub depending on the type, and severity of tamponade. Initial diagnosis can be challenging, as there are a number of differential diagnoses, including tension pneumothorax, and acute heart failure.

Physical Examination

Appearance of the Patient

Beck's triad ^[1]^[2]

The American thoracic surgeon, Beck, has described two clinical triad in 1930. The clinical triads are for both cardiac tamponade and pericardial constriction.

Beck's Triad for Tamponade	Beck's Triad Pericardial Constriction
▸ Hypotension (due to decreased stroke volume)	▸ Ascites
▸ Jugular venous distension (due to impaired venous return to the heart)	▸ High venous pressure
▸ Muffled heart sounds (due to fluid inside the pericardium) ^[3]	▸ Small quiet heart

Distension of veins in the forehead and scalp
Altered sensorium (decreasing Glasgow coma scale) due to hypotension
Peripheral edema due to high venous pressure

It should be noted that Beck's triad was descriped for the tamponade casued by acute intrapericardial hemorrhage, eg, traumatic causes of tamponade. This may not apply to other more slowly progressive forms of tamponade associated with a variety of medical conditions as opposed to surgical causes.^[4]

Vital Signs

Sinus tachycardia - common finding on physical examination and seen as an adaptive response of the body towards hypotension.
Pulsus paradoxus (a drop of > 10 mmHg in arterial blood pressure on inspiration)
Diminished peripheral pulses

Skin

Skin examination of patients with cardiac tamponade is usually normal.

HEENT

HEENT examination of patients with cardiac tamponade is usually normal.

Neck

Jugular venous distension
Carotid bruits may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope.

Lungs

Pulmonary crackles may be heared due to acute pulmonary edema.

Cardiovascular

Auscultation

In addition to the Beck's triad and pulsus paradoxus the following can be found on cardiovascular examination:

Pericardial rub
Clicks - As Ventricular volume shrinks disproportionately, there may be psuedoprolapse/true prolapse of mitral and/or tricuspid valvular structures that result in clicks.
Kussmaul's sign - Decrease in jugular venous pressure with inspiration is uncommon.

Pulsus Paradoxus

The following video depicts and explains the concept of pulsus paradoxus. {{#ev:youtube|jTsjCZ9QxW8}}

Abdomen

Abdominal examination of patients with cardiac tamponade is usually normal.

Back

Back examination of patients with cardiac tamponade is usually normal.

Genitourinary

Genitourinary examination of patients with cardiac tamponade is usually normal.

Neuromuscular

Neuromuscular examination of patients with cardiac tampnoade is usually normal.

Extremities

Extremities examination of patients with cardiac tamponade is usually normal.

References

↑ Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097
↑ Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097
↑ Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395
↑ Guberman, BA.; Fowler, NO.; Engel, PJ.; Gueron, M.; Allen, JM. (1981). "Cardiac tamponade in medical patients". Circulation. 64 (3): 633–40. PMID 6455217. Unknown parameter |month= ignored (help)

Template:WS Template:WH CME Category::Cardiology

[1] Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097

[2] Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097

[3] Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395

[Guberman-1981-4] Guberman, BA.; Fowler, NO.; Engel, PJ.; Gueron, M.; Allen, JM. (1981). "Cardiac tamponade in medical patients". Circulation. 64 (3): 633–40. PMID 6455217. Unknown parameter |month= ignored (help)

[1]

[2]

[3]

[4]

@@ Line 1: / Line 1: @@
+__NOTOC__
 {{Cardiac tamponade}}
-{{CMG}}; '''Associate Editors-In-Chief:''' {{CZ}}; [[Varun Kumar]], M.B.B.S.
+{{CMG}}; {{AE}} {{CZ}}; [[Varun Kumar]], M.B.B.S.; {{AZ}} {{RG}}
 ==Overview==
-Physical examination may vary depending on the type of [[cardiac tamponade]]. Physical examination may show the classic [[Beck's triad]] ([[hypotension]], [[muffled heart sound]], and elevated [[jugular venous distension]]), [[tachycardia]], [[pulsus paradoxsus]], and [[pericardial rub]] depending on the type, and severity of tamponade.
+Physical examination may vary depending on the type of [[cardiac tamponade]]. Physical examination may show the classic [[Beck's triad]] ([[hypotension]], [[muffled heart sound]], and elevated [[jugular venous distension]]), [[tachycardia]], [[pulsus paradoxus]], and [[pericardial rub]] depending on the type, and severity of tamponade. Initial diagnosis can be challenging, as there are a number of [[differential diagnosis|differential diagnoses]], including [[tension pneumothorax]], and acute [[heart failure]].
 ==Physical Examination==
-Initial diagnosis can be challenging, as there are a number of [[differential diagnosis|differential diagnoses]], including [[Tension pneumothorax]] <ref>Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097 </ref>, and acute heart failure.
+===Appearance of the Patient===
+* [[Beck's triad]] <ref>Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097 </ref><ref>Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097 </ref>
-Classical cardiac tamponade presents three signs, known as [[Beck's triad]]<ref>Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097 </ref>.  [[Hypotension]] occurs because of decreased [[stroke volume]], [[jugular venous distension]] due to impaired venous return to the heart, and muffled [[heart sounds]] due to fluid inside the pericardium <ref>Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395</ref> Another sign of tamponade on physical examination includes [[pulsus paradoxus]] (a drop of at least 10 mmHg in arterial blood pressure on inspiration) <ref>Mattson Porth, C. (Ed.) (2005) (7th Ed.) Pathophysiology: Concepts of Altered Health States. Philadelphia : Lippincott Williams & Wilkins ISBN 978-0781749886 </ref>. There may also be general signs & symptoms of cardiogenic [[shock]] (such as [[tachycardia]], [[breathlessness]], poor perfusion of the extremities and decreasing [[Glasgow coma scale|level of consciousness]]). [[Peripheral edema]] may be present. Hemodynamic changes diminish S<sub>1</sub> and S<sub>2</sub> .  As Ventricular volume shrinks disproportionately, there may be psuedoprolapse/true prolapse of mitral and/or tricuspid valvular structures that result in clicks.
+The American thoracic surgeon, Beck, has described two clinical triad in 1930. The clinical triads are for both cardiac tamponade and pericardial constriction.
-==Pulsus paradoxsus==
+{|
+|-
+| valign=top |
+{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:60em" cellpadding="0" cellspacing="0";
+! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=left | ''{{fontcolor|#6C7B8B|Beck's Triad for Tamponade }}'' !! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=left | ''{{fontcolor|#6C7B8B|Beck's Triad Pericardial Constriction }}''
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Hypotension]] (due to decreased [[stroke volume]])''''' ||  style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ascites]]'''''
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Jugular venous distension]] (due to impaired venous return to the heart)''''' ||  style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ ''''' [[High venous pressure]]'''''
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''Muffled [[heart sounds]] (due to fluid inside the pericardium) <ref>Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395</ref>''''' ||  style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Small quiet heart]]'''''
+|-
+|}
+|}
+* Distension of veins in the forehead and scalp
+* Altered sensorium (decreasing [[Glasgow coma scale]]) due to hypotension
+* [[Peripheral edema]] due to high venous pressure
+It should be noted that Beck's triad was descriped for the tamponade casued by acute intrapericardial hemorrhage, eg, traumatic causes of tamponade. This may not apply to other more slowly progressive forms of tamponade associated with a variety of medical conditions as opposed to surgical causes.<ref name="Guberman-1981">{{Cite journal  | last1 = Guberman | first1 = BA. | last2 = Fowler | first2 = NO. | last3 = Engel | first3 = PJ. | last4 = Gueron | first4 = M. | last5 = Allen | first5 = JM. | title = Cardiac tamponade in medical patients. | journal = Circulation | volume = 64 | issue = 3 | pages = 633-40 | month = Sep | year = 1981 | doi =  | PMID = 6455217 }}</ref>
+===Vital Signs===
+* [[Sinus tachycardia]] - common finding on physical examination and seen as an adaptive response of the body towards [[hypotension]].
+* [[Pulsus paradoxus]] (a drop of > 10 mmHg in arterial blood pressure on inspiration)
+* Diminished peripheral [[pulses]]
+===Skin===
+* Skin examination of patients with cardiac tamponade is usually normal.
+===HEENT===
+* HEENT examination of patients with cardiac tamponade is usually normal.
+===Neck===
+*[[Jugular venous distension]]
+*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope.
+===Lungs===
+*Pulmonary crackles may be heared due to acute pulmonary edema.
+===Cardiovascular===
+====Auscultation====
+In addition to the Beck's triad and pulsus paradoxus the following can be found on cardiovascular examination:
+* [[Pericardial rub]]
+* Clicks - As Ventricular volume shrinks disproportionately, there may be psuedoprolapse/true prolapse of mitral and/or tricuspid valvular structures that result in clicks.
+* [[Kussmaul's sign]] - Decrease in jugular venous pressure with inspiration is uncommon.
+====Pulsus Paradoxus====
+The following video depicts and explains the concept of pulsus paradoxus.
 {{#ev:youtube|jTsjCZ9QxW8}}
+===Abdomen===
+* Abdominal examination of patients with cardiac tamponade is usually normal.
+===Back===
+* Back examination of patients with cardiac tamponade is usually normal.
+===Genitourinary===
+* Genitourinary examination of patients with cardiac tamponade is usually normal.
+===Neuromuscular===
+* Neuromuscular examination of patients with cardiac tampnoade is usually normal.
+===Extremities===
+* Extremities examination of patients with cardiac tamponade is usually normal.
 ==References==
 {{Reflist|2}}
+{{WS}}
+{{WH}}
+[[CME Category::Cardiology]]
+[[Category:Cardiology]]
+[[Category:Echocardiography]]
+[[Category:Intensive care medicine]]
 [[Category:Chest trauma]]
-[[Category:Cardiology]]
 [[Category:Diseases involving the fasciae]]
 [[Category:Emergency medicine]]
+[[Category:Disease]]
-{{WS}}
-{{WH}}