Management of Pericardial Effusion in an Emergency

Introduction:

A fibrous sac (the pericardium) surrounds and encloses the heart to keep it in position and separates it from adjacent structures and organs, such as the lungs. The pericardium is also essential for normal heart function. Fluid accumulation around the heart in the pericardial sac is known as pericardial effusion. The pericardium usually contains a thin layer of fluid. However, excess fluid can build up around the heart if it gets injured, inflamed, or diseased. In addition, other conditions, such as bleeding due to chest trauma or cancer, can cause fluid accumulation in the pericardium. This excess fluid accumulation exerts pressure, compresses the heart, and affects the heart's function. Pericardial effusion is a medical emergency that requires immediate attention, as it could lead to heart failure and death.

What Are the Causes of Pericardial Effusions?

Pericardial effusion can result from the following conditions:

• Injury to the chest.

• Cancer.

• Autoimmune disorders (the body’s defense mechanism overreacts, attacks, and destroys normal cells and tissues).

• Radiation to the heart (during therapy).

• Inflammation of the pericardium (after heart procedures or heart attack).

• Medications.

• Drugs and toxins.

• Hypothyroidism.

• Infections.

• Kidney failure.

What Are the Main Symptoms of Pericardial Effusions?

Pericardial effusion symptoms depend on the severity of the condition. The symptoms of pericardial effusion are:

1. Shortness of breath.

2. Chest pain and discomfort.

3. Rapid heartbeat.

4. Palpitations.

5. Dizziness.

6. Behavioral changes such as anxiety or confusion.

7. Bluish discoloration of the skin, lips, and nails due to low oxygen levels in the blood.

8. Hiccups, coughing, or trouble swallowing (when large pericardial effusions impinge on the surrounding nerves and tissues).

How Is Pericardial Effusion Diagnosed?

Various tests are performed to diagnose and confirm pericardial effusion. These include:

1. Echocardiogram: This imaging test shows the heart in motion and helps to determine if excess fluid is present in the pericardium. It can help to diagnose if the heart function is affected due to the excess pressure on the heart (cardiac tamponade).

2. Electrocardiogram (ECG): This test measures the heart's electrical activity and helps check heart function.

3. Chest X-ray: This imaging helps to analyze the size and shape of the heart. Signs of an enlarged heart can be seen if the pericardial effusion is large.

4. Other Tests: Other imaging tests, such as computed tomography and magnetic resonance imaging (MRI), can also help diagnose pericardial effusion but are not usually used specifically for effusion diagnosis.

How Are Small Pericardial Effusions Managed?

The treatment for pericardial effusion can range from watchful waiting (to see if emergency interventions are required) to immediate interventions to manage the cause. Small pericardial effusions that do not immediately threaten the patient's life are monitored with serial imaging (echocardiography) if necessary. Conversely, some pericardial effusions do not require continuous imaging or follow-up. If the pericardial effusion is not immediately life-threatening, it is managed with medications and other treatment options depending on the underlying cause. These include:

1. Antibiotics: If the pericardial effusion has resulted from underlying infections such as tuberculosis, appropriate antibiotics are administered to treat the cause.

2. Anti-inflammatory drugs: If the pericardial effusion has resulted from inflammation and swelling of the pericardium, these are administered.

3. Chemotherapy and Radiation Therapy: These are initiated if the pericardial effusion has resulted from cancer.

4. Heart Failure Medications and Diuretics: These are administered when the pericardial effusion has resulted from heart failure.

How Are Life-Threatening Pericardial Effusions Managed?

Pericardial effusion is managed depending on its severity and the cause. Minor effusions are not considered dangerous and do not require emergency management. However, large pericardial effusions can cause cardiac tamponade (due to excess pressure on the heart) and thus must be managed immediately. Pleural effusions that have rapidly accumulated and grown to affect heart function and cause a collapse are immediately managed at the bedside or in the operating room. The various treatment options for large pericardial effusions in an emergency include:

• Pericardiocentesis (Needle Aspiration):

• Pericardiocentesis can be done to identify the cause of the pericardial effusion and to drain the excess fluid to provide symptomatic relief (for patients with chest pain, discomfort, and edema). A trained healthcare provider aspirates the excess fluid in the pericardium by inserting a needle into the patient's chest. A numbing agent is used to prevent pain during the procedure. Imaging tools such as echocardiography or fluoroscopy are used to guide the needle to the sac around the heart to pull out the excess fluid or blood. At times, some patients may require a continuous drain (a thin tube is left inside the patient's pericardium to drain out the fluid) for a few days until the patient feels better.

• Patients with large pericardial effusion with underlying heart ventricular dysfunction are at risk of developing life-threatening complications such as pericardial decompression syndrome after pericardiocentesis. Thus, such patients are continuously monitored and handled with care to prevent the occurrence of complications. In order to avoid complications due to the sudden removal of the large volume of fluid from the pericardium, the healthcare personnel removes only sufficient fluid to regain efficient heart function and places a continuous drain to gradually remove the excess fluid.

• Surgery: In emergencies, surgery is performed to relieve pressure around the heart immediately. Surgery can be done as an emergency procedure or can be scheduled (if the effusion is not life-threatening or minor, slow growing). Video-assisted thoracic surgery (VATS) is the common surgical procedure used to drain excess fluid or blood around the heart. A pericardial window is created in the surgery to let the fluid in the pericardium spill out without filling up the space around the heart.

What Is the Algorithm Used for Managing Pericardial Effusion?

1. The patient is checked for signs of excess pressure on the heart (cardiac tamponade). The patients are also assessed for possible or suspected underlying causes, such as bacterial infection or cancer.

2. If the heart function is affected due to excess pressure, immediate pericardiocentesis is performed.

3. Efforts are made to identify the underlying cause.

4. If the heart function is normal, and there are no signs of tamponade, the patient is tested for inflammatory markers (blood test). Empiric anti-inflammatory therapy is initiated if inflammatory markers are raised in the blood.

5. If the inflammatory cause (pericarditis) is ruled out, efforts are initiated to assess the presence of any known associated disease causing the effusion. Once the disease leading to the effusion is identified, it is managed based on the cause.

6. If there is no underlying disease and the pericardial effusion is large, immediate pericardiocentesis or surgery is performed to save the patient’s life. Continuous imaging and follow-up are mandatory in such scenarios.

Conclusion:

Pericardial effusion is a condition in which fluid accumulates in the sac surrounding the heart. It can exert pressure on the heart and can be life-threatening. Large pericardial effusions are medical emergencies that require emergency care. The various treatment options include antibiotics, anti-inflammatory drugs, and other medications for small effusions. Larger effusions require drainage of the fluid around the heart and surgical interventions. The treatment depends on the underlying cause of the pericardial effusion and the severity of the condition.