Endgames Picture Quiz

Signs of shock and raised jugular venous pressure

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2643 (Published 20 April 2012) Cite this as: BMJ 2012;344:e2643
  1. Daniel Keene, foundation year 2 doctor1,
  2. Anjali Gopinath, foundation year 1 doctor1,
  3. William Watson, foundation year 1 doctor2,
  4. Clint Maart, cardiology registrar1,
  5. Awais Bokhari, consultant cardiologist1
  1. 1Cardiology Department, Bedford Hospital, Bedford MK42 9DJ, UK
  2. 2Cambridge University Hospital, Intensive Care, Cambridge, UK
  1. Correspondence to: D Keene drkeene{at}doctors.org.uk

A 38 year old white man presented to the emergency department with a three month history of progressively worsening shortness of breath. He had also experienced other vague symptoms over the same period, including muscle aches, weakness, pains associated with fatigue, and noticeable weight loss. Having previously been fit and well, he was now struggling to climb the stairs at home. The onset of symptoms coincided with an episode of food poisoning; he denied any recent travel.

On clinical examination he had quiet heart sounds, with a raised jugular venous pressure, which rose on inspiration. He showed signs of haemodynamic compromise and shock, with a heart rate of 115 beats/min, blood pressure of 105/75 mm Hg but no postural drop, respiratory rate of 24 breaths/min, and oxygen saturations of 95% on room air. Chest radiography (fig 1) and electrocardiography showed classic changes. The results of these investigations prompted immediate point of care transthoracic echocardiography (fig 2). After consent, he was promptly admitted to the cardiac catheterisation laboratory for immediate intervention.


  • 1 What abnormalities can be seen on the chest radiograph and echocardiogram?

  • 2 What clinical abnormality was suspected, and what are the classic electrocardiographic abnormalities seen with this condition?

  • 3 What is the most likely cause of this condition in this patient?

  • 4 What classic signs were elicited in this patient? What other sign might have been elicited to point towards the diagnosis?

  • 5 How should this patient be managed?


1 What abnormalities can be seen on the chest radiograph and echocardiogram?

Short answer

The chest radiograph shows a globular cardiac silhouette (fig 1), possibly as a result of fluid surrounding the heart. The echocardiogram shows a large pericardial effusion (fig 3).


Fig 3 Echocardiogram showing evidence of a pericardial effusion (white arrow)

Long answer

A large cardiac silhouette with the typical “water bottle” or “globular” appearance on a chest radiograph should raise suspicion of a pericardial effusion. Acute presentations may not be evident on radiography because at least 200 ml of fluid must be present before the cardiac silhouette is affected.1 2 The presence of these features on a chest radiograph is suggestive of a pericardial effusion but is not diagnostic.

An echocardiogram is the imaging modality of choice for detecting pericardial effusion.3 It shows an area of reduced echogenicity or a fluid layer around the myocardium. “Swinging” of the heart—where the heart moves within the fluid sac with inspiration and expiration—can be seen with a large pericardial effusion.4 A dilated inferior vena cava with a lack of inspiratory collapse may also be noted. A characteristic sign with good specificity but low sensitivity is right ventricular collapse in early diastole (fig 4) and right atrial collapse in late diastole. A small proportion of cases show left atrial collapse, which is highly specific for the presence of cardiac tamponade.2 5


Fig 4 Parasternal long axis view show right ventricular collapse during diastole (white arrow)

2 What clinical abnormality was suspected, and what are the classic electrocardiographic abnormalities seen with this condition?

Short answer

Cardiac tamponade. Electrocardiography classically shows diffuse decreased QRS voltages and may display electrical alternans.

Long answer

The patient’s symptoms and imaging findings suggest a diagnosis of cardiac tamponade. The build up of fluid between the myocardium and pericardium causes compression of the heart and reduces right ventricular diastolic filling, resulting in cardiovascular compromise. Although electrocardiography is poor at diagnosing the presence of a pericardial effusion or cardiac tamponade, some abnormalities are classically associated. The first is decreased QRS complex voltages, which is seen more commonly with large effusions because of the increased distance between the myocardium and the chest wall.6

True electrical alternans is a relatively rare feature.4 Alternating high and low amplitudes of the QRS height caused by “swinging” of the heart within the fluid filled pericardial space can result in alternation in electrical transmission during the electrocardiographic recording (fig 5).


Fig 5 Decreased QRS voltages and electrical alternans on electrocardiography

3 What is the most likely cause of this condition in this patient?

Short answer

In view of the slow onset, associated weight loss, and other systemic symptoms, cancer is the most likely diagnosis. In developing countries tuberculosis should also be considered.

Long answer

No identifiable cause of cardiac tamponade is found in 30-40% of cases.7 Cancer is the most common cause, accounting for about 30% of cases.8 9 Lung cancer is the most common associated cancer in men, whereas breast cancer is the most common one in women.10 Pericarditis in the form of infections (viral, bacterial, fungal) is another common cause (20% of cases). Although tuberculosis is relatively uncommon in the UK, it is a leading cause of pericardial effusions in the developing world.

Inflammatory processes such as rheumatoid arthritis, Dressler’s syndrome, and uraemia are seen in 10-20% of cases.8 11

Iatrogenic tamponade secondary to invasive procedures or cardiac surgery is the most common cause of haemorrhagic tamponade (30%), followed closely by cancer.12

Myocardial infarction causing rupture of the ventricular free wall accounts for less than 1% of cases if appropriate fibrinolytic treatment is started early. Development of subsequent cardiac tamponade is however associated with increased 30 day mortality.13 Other less common causes of cardiac tamponade include blunt chest trauma, aortic dissection type A,14 and hypothyroidism.15

4 What classic signs were elicited in this patient? What other sign might have been elicited to point towards the diagnosis?

Short answer

Beck’s triad and Kussmaul’s sign were seen in this patient. Pulsus paradoxus could be looked for.

Long answer

Cardiac tamponade often presents with symptoms of dyspnoea, tachycardia, and a raised jugular venous pressure (with a prominent x descent and absence of the y wave) (fig 6). Our patient also showed Kussmaul’s sign—a rise in jugular venous pressure on inspiration.


Fig 6 (A) Normal jugular venous pressure waveform. (B) Jugular venous pressure waveform associated with cardiac tamponade, including prominent x descent and absence of y descent

Pulsus paradoxus is an exaggeration of the normal drop in blood pressure seen during inspiration. A drop of more than 10 mm Hg is highly suggestive of cardiac tamponade. Although this sign has a high sensitivity for the presence of cardiac tamponade, some coexisting conditions such as ventricular hypertrophy, heart failure, and severe aortic regurgitation can mask its presence.16 Beck described the cardiac compression triad of a falling arterial pressure, raised venous pressure, and quiet heart sounds.17 Although this is characteristic in acute tamponade, these signs are absent in many patients who develop progressive effusions. Imaging is usually needed for diagnostic certainty.

5 How should this patient be managed?

Short answer

Urgent pericardiocentesis under fluoroscopy or echocardiographic guidance should be undertaken. Fluid should be sent for cytology, protein count, and microbiology. The underlying cause of the tamponade will need appropriate management.

Long answer

Pericardiocentesis is the mainstay of management in cardiac tamponade. Large pericardial effusions without tamponade may not require pericardiocentesis if a more appropriate management option exists, such as renal dialysis for effusions associated with uraemic pericarditis.2 11 Drainage should ideally be under echocardiographic or fluoroscopic guidance, but this may not be feasible in the event of sudden circulatory collapse or in pulseless electrical activity.2 An indwelling drainage catheter is usually left in situ after the intervention and is removed when the volume draining over 24 hours is less than 50 ml.1

Fluid from drainage should be sent for cytology, protein count, microbiology, and tuberculosis screen.

Medical management has limited value and is mainly supportive.

Surgical approaches include a pericardial “window” for recurrent effusions, which allows the fluid to drain into the peritoneal cavity, where its effects are less serious. Thoracotomy with pericardiotomy is the most definitive management option but has limited use because it is a major operation.18 Percutaneous balloon pericardiotomy provides a less invasive alternative to surgery and is generally well tolerated by patients.19 In patients with malignant effusions, intrapericardial instillation of sclerosing agents or chemotherapeutic agents (such as tetracyclines or cisplatin) during pericardiocentesis reduces recurrence.18

Patient outcome

Our patient went on to have computed tomography of the chest, abdomen, and pelvis, which showed a large renal mass with extensive lung and bone metastases. Other tests including an immunology screen and tuberculosis screen were negative. Cytology of the pericardial fluid was positive for malignant cells consistent with a metastatic adenocarcinoma and primary renal tumour. He was transferred to the care of the oncologists.


Cite this as: BMJ 2012;344:e2643


  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.


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