Resuscitation 82 (2011) 671–673 Contents lists available at ScienceDirect Resuscitation journal homepage: www.elsevier.com/locate/resuscitation Commentary and concepts Point-of-care ultrasound evaluation of pericardial effusions: Does this patient have cardiac tamponade?  Arun Nagdev * , Michael B. Stone Department of Emergency Medicine, Highland General Hospital, 1411 East 31st Street, Oakland, CA 94602, United States article info Article history: Received 28 July 2010 Received in revised form 23 January 2011 Accepted 3 February 2011 Keywords: Echocardiography Cardiac tamponade Inferior vena cava abstract Detection of pericardial effusions using point-of-care focused echocardiography is becoming a common application for clinicians who care for critical patients. Identification of tamponade physiology is of great utility, as these patients require urgent evaluation and management. We describe techniques that the point-of-care clinician sonographer can use to determine the presence or absence of echocardiographic evidence of cardiac tamponade. © 2011 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Evaluation of the patient in shock or pulseless electrical activity must include prompt recognition of reversible causes of hemody- namic instability. Among these, identification of cardiac tamponade is of particular importance as treatment is disease-specific, requir- ing emergent drainage of pericardial fluid. Unfortunately, detection of cardiac tamponade using classic physical exam signs such as Beck’s triad of hypotension, distended neck veins and muffled heart sounds can be quite inaccurate. 1 Transthoracic echocardiography is the study of choice for the rapid and safe evaluation of pericardial effusions. 2 It is non- invasive, performed at the bedside, and has the distinct advantage of detecting evidence of impending cardiac tamponade in patients who have not yet developed hypotension. Classically, cardiac tam- ponade is defined as a condition in which the pericardial fluid impinges on cardiac function, decreasing cardiac output. Echocar- diographic evaluation allows for detection of subclinical signs of cardiac dysfunction, allowing the clinician the ability to make the diagnosis much earlier on the continuum of disease. Increasingly, clinicians at the patient’s point-of-care (such as emergency physicians and intensivists) have adopted the use of focused point-of-care cardiac ultrasound (PCU) to aid in the eval- uation of the critically ill, and have demonstrated competency in basic cardiac evaluations such as detection of pericardial effusion  A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.02.004. * Corresponding author. Tel.: +1 401 623 9106. E-mail address: arunnagdev@gmail.com (A. Nagdev). and assessment of global left ventricular function. 3–5 Although clin- icians may be able to accurately identify pericardial effusions, the majority of these effusions are not associated with tamponade physiology. Determination of the presence or absence of impend- ing cardiac tamponade is therefore of considerable importance to clinicians caring for the normotensive patient with a pericardial effusion. Echocardiographic evidence of cardiac tamponade is character- ized by (1) diastolic collapse of the right ventricle and right atrium, (2) exaggerated respiratory variations of transmitral and transtri- cuspid Doppler inflow velocities, and (3) inferior vena cava (IVC) plethora. 6–9 These findings will be discussed as they apply to the point-of-care clinician-sonographer who wishes to determine if echocardiographic evidence of tamponade exists. 2. Point-of-care cardic ultrasound (PCU) for tamponade 2.1. Chamber collapse Diastolic collapse of the cardiac chambers (particularly the right ventricle and right atrium) is the most commonly cited criteria for echocardiographic confirmation of tamponade physiology. 10 Clinicians who perform PCU, however, have traditionally been at a considerable disadvantage when attempting to determine if diastolic chamber collapse exists. Comprehensive (consultative) transthoracic echocardiography is performed with real-time ECG monitoring which correlates echocardiographic findings with the phase of the cardiac cycle. Therefore, diastolic versus systolic chamber collapse is easily differentiated. PCU is often performed without real-time ECG monitoring, and clinicians may not be able 0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2011.02.004