Cardiac tamponade physical examination

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]

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.

• 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.

• 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]

• 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 examination of patients with cardiac tamponade is usually normal.

• HEENT examination of patients with cardiac tamponade is usually normal.

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

• Pulmonary crackles may be heared due to acute pulmonary edema.

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.

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

• Abdominal examination of patients with cardiac tamponade is usually normal.

• Back examination of patients with cardiac tamponade is usually normal.

• Genitourinary examination of patients with cardiac tamponade is usually normal.

• Neuromuscular examination of patients with cardiac tampnoade is usually normal.

• Extremities examination of patients with cardiac tamponade is usually normal.

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