Hypotension + ↑JVP + muffled sounds (Beck); pulsus paradoxus >10 mmHg; electrical alternans; effusion/post-MI
ABCDE
O₂, IV fluids to bridge; urgent echo; pericardiocentesis without delay if unstable.
Temporize: Normal saline boluses IV to raise BP (recheck after each bolus)
Definitive — do NOT wait for echo/cath: Pericardiocentesis (removing even ~50 mL restores filling)
Decision tree
Haemodynamically unstable?
YesIV fluids to bridge → urgent pericardiocentesis (don't wait for imaging)
NoEcho to confirm; monitored pericardiocentesis; treat cause
Order set
- Urgent echo
- ECG (electrical alternans)
- IV fluids
- Prepare pericardiocentesis
Escalate / ICU
- Hemodynamic collapse
- Emergent pericardiocentesis
- Recurrent effusion → window
Criteria
AdmitAll tamponade
ICUPeri/post-drainage monitoring, recurrence
VasopressorsBridge only until drainage
DischargeEffusion drained, cause treated, no re-accumulation on echo
Never
- Give diuretics/vasodilators — worsens filling
Key
- Earliest echo sign = diastolic RA/RV collapse.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Beck triad
- Pulsus paradoxus
- Hemodynamic collapse
Differentials
- Tension pneumothorax
- Massive PE
- RV infarct
- Constrictive pericarditis
Common mistakes
- Diuretics/vasodilators
- Waiting for imaging before draining unstable patient
Disposition & follow-up
Drain; treat cause; monitor for re-accumulation.
Discharge package
MedicationsTreat underlying cause (e.g., colchicine/NSAID if pericarditic)
Follow-upRepeat echo for re-accumulation
Warning symptomsBreathlessness, chest pain, dizziness
💊 Treatment detail — doses & preparation
0.9% Sodium chloridecrystalloid
DoseBolus 500 mL over 15–30 min, reassess; maintenance 1–1.5 mL/kg/h
Preparation500/1000 mL bags; add KCl only after urine output confirmed
MonitorHyperchloraemic acidosis with large volumes — prefer balanced (LR) for resuscitation
Noradrenaline (norepinephrine)vasopressor
Dose0.05–1 mcg/kg/min IV infusion, titrate to MAP ≥65
Preparation4 mg in 250 mL D5W or NS (16 mcg/mL) via infusion pump; central line preferred — proximal peripheral vein acceptable short-term
MonitorContinuous invasive MAP; check limb perfusion, urine output; wean gradually, never stop abruptly
Pericardiocentesisdefinitive
DoseEcho-guided needle drainage — removing even 50 mL restores filling
PreparationSubxiphoid approach, echo guidance, monitor on
MonitorWatch for re-accumulation; send fluid for cytology/culture
📖 ESC Pericardial DiseasesReviewed July 2026