Answer: A. Immediate transfer to the hospital for pericardiocentesis; consider administering intravenous fluids while waiting for emergency transportation to arrive
The clinical scenario is one of a patient with pericardial effusion and tamponade. The key clinical findings are attenuated heart sounds, tachycardia, hypotension, and most importantly, the finding of pulsus paradoxus on examination.1 Pulsus paradoxus is defined as a 10-mm Hg drop in systolic pressure during inspiration.1 Although obtaining an echocardiogram would be ideal to confirm the diagnosis, delaying care for an outpatient echocardiogram would not be recommended for this patient, who has cardiogenic shock. Hence, choice C is the wrong answer.
The patient has no signs of volume overload; therefore, choice E is incorrect. However, once in the emergency department or the catheterization laboratory, it would be reasonable to obtain a 2-dimensional echocardiogram immediately to look for hemodynamic markers of tamponade and guide needle aspiration while the interventional team prepares for pericardial drainage.
Given the recent fevers and the current hypotension and tachycardia, this patient likely has hypovolemia. Intravenous fluids may be a reasonable stabilizing intervention while awaiting pericardiocentesis. Nevertheless, the use of intravenous fluids in patients with euvolemia or hypervolemia is controversial and may increase intracardiac pressures and volume, which in turn may increase the pericardial pressures and thus reduce cardiac output.1
Choices B and D are incorrect because the patient has cardiogenic shock, which is a medical emergency, and there is no role for steroid medications in tamponade.
1. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684-690.