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cardio.cardiac-tamponade.core.v1PRODUCTION
cardio.cardiac-tamponade.core.v1

Cardiac tamponade

cardiologyacuteadult
Hard-required inputs
0 / 4
Care setting:

Encounter flow

9/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Time-critical decompensation — pericardiocentesis is curative (ESC 2015 Class I)

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Advance rule
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tamponade physiology suspected

Patient inputs (8)

Etiology distribution (malignant vs idiopathic vs uremic; Ristić EHJ 2014 triage classification)

Compensatory tachycardia (ESC 2015 §Clinical Presentation)

Definitive bedside dx — chamber collapse, IVC, swinging heart (ESC 2015 Class I, Recommendation)

Hypotension is part of Beck triad; pulsus paradoxus measurement (Spodick Circulation 2003)

Malignant effusion = top etiology in oncology pts (Ristić EHJ 2014)

Post-PCI/ablation/surgery tamponade (ESC 2015 §Iatrogenic Tamponade)

Acute or recurrent pericarditis precedent (Adler et al 2015)

AC + post-procedure raises hemorrhagic tamponade risk (ESC 2015 §Iatrogenic Tamponade)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateninghemodynamic_instability_in_tamponade — ESC 2015 Class I
    SBP <90 + Beck triad + echo confirms tamponade physiology (Spodick Circulation 2003; ESC 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemorrhagic_tamponade
    Tamponade from Type A dissection / post-PCI/ablation / trauma / AC + post-procedure (ESC 2015 §Iatrogenic Tamponade)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremalignant_effusion
    Tamponade in known/new cancer with malignant cells on cytology (Ristić EHJ 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_effusion_post_drainage
    Re-accumulation within 7 days of initial drainage (ESC 2015 §Recurrent Pericardial Effusion)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereuremic_pericarditis
    Tamponade in ESRD / advanced CKD (ESC 2015 §Uremic Pericarditis)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateeffusive_constrictive
    Persistent elevated RA pressure after pericardial drainage despite resolved effusion (ESC 2015 §Effusive-Constrictive Pericarditis)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Tamponade — pericardiocentesis-first with bridge therapy (ESC 2015 Class I)
axis: tamponade_drainagestep 1 - Step 1 — Bridge to drainage (NEVER substitute for drainage; ESC 2015 §Tamponade Management)
Selected step "Step 1 — Bridge to drainage (NEVER substitute for drainage; ESC 2015 §Tamponade Management)" — Hemodynamically unstable awaiting pericardiocentesis or surgical window (Adler et al 2015)
  • normal saline
    first line
    isotonic_crystalloid
    500–1000 mL bolus • IV • rapid bolus then reassess
    triggers: hypotension_pre_drainage
    Increase preload to overcome pericardial restriction; reassess after 500 mL (ESC 2015 §Tamponade Management; Spodick Circulation 2003)
    rxcui 9863
  • norepinephrine
    rescue
    vasopressor
    0.05–0.1 µg/kg/min • IV • continuous; titrate to MAP ≥65
    triggers: SBP_lt_85_despite_fluids
    Bridge only — does not address obstruction (Roy JAMA 2007)
    rxcui 7512
  • dobutamine
    rescue
    inotrope_beta1
    2.5 µg/kg/min • IV • continuous
    triggers: low_CO_after_drainage
    For post-drainage low-output state (ESC 2015 §Post-Drainage Management)
    rxcui 3616

outpatient playbook — drug actions (3)

  1. 1. colchicine continuation per duration plan
    rxcui 2683
    0.5 mg BID through 3 mo (first episode) or 6 mo (recurrence) — verify with eGFR • PO • BID
    trigger: Outpatient maintenance
    ESC 2015 Class I; ICAP/CORP/CORP-2 evidence base
  2. 2. NSAID taper completed
    rxcui 5640
    DC by 4–6 wk if CRP normal × 2 visits • PO • taper to off
    trigger: CRP normalized × 2 consecutive visits
    ESC 2015 §Tapering (avoid abrupt withdrawal — rebound risk)
  3. 3. IL-1 antagonist referral
    anakinra 100 mg SC daily OR rilonacept 320 mg SC loading then 160 mg weekly • SC • per agent
    trigger: ≥2 recurrences despite optimal colchicine + NSAID
    AIRTRIP (PMID 27825009) HR 0.10 vs placebo; RHAPSODY (PMID 33200890) HR 0.04 — Class IIa in ESC 2015 §Recurrent Pericarditis. Owner: cardio.pericarditis.core.v1 — referral only here.

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Dyspnea + hypotension + JVD (Beck triad; Spodick Circulation 2003); Echo: pericardial effusion + RV diastolic collapse / IVC plethora (ESC 2015 §Tamponade Diagnosis); Pulsus paradoxus >10 mmHg (Roy JAMA 2007; Spodick Circulation 2003).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiac tamponade** (cardio.cardiac-tamponade.core.v1).
Phenotype framing: Effusive vs effusive-constrictive vs constrictive; etiology subtyping (Adler et al 2015 Table 4)
Scope: Time-critical decompensation — pericardiocentesis is curative (ESC 2015 Class I)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Tamponade — pericardiocentesis-first with bridge therapy (ESC 2015 Class I)** — step "Step 1 — Bridge to drainage (NEVER substitute for drainage; ESC 2015 §Tamponade Management)".
1. normal saline 500–1000 mL bolus IV rapid bolus then reassess (isotonic_crystalloid, first line) — Increase preload to overcome pericardial restriction; reassess after 500 mL (ESC 2015 §Tamponade Management; Spodick Circulation 2003)
2. norepinephrine 0.05–0.1 µg/kg/min IV continuous; titrate to MAP ≥65 (vasopressor, rescue) — Bridge only — does not address obstruction (Roy JAMA 2007)
3. dobutamine 2.5 µg/kg/min IV continuous (inotrope_beta1, rescue) — For post-drainage low-output state (ESC 2015 §Post-Drainage Management)

Setting playbook (outpatient) — Long-term surveillance for pericarditis recurrence + complete colchicine taper + transition to chronic pericarditis engine if recurrent (ESC 2015 §Long-term Follow-up; Khandaker Mayo Clin Proc 2010 PMID 20511488)
4. colchicine continuation per duration plan 0.5 mg BID through 3 mo (first episode) or 6 mo (recurrence) — verify with eGFR PO BID — Outpatient maintenance (ESC 2015 Class I; ICAP/CORP/CORP-2 evidence base)
5. NSAID taper completed DC by 4–6 wk if CRP normal × 2 visits PO taper to off — CRP normalized × 2 consecutive visits (ESC 2015 §Tapering (avoid abrupt withdrawal — rebound risk))
6. IL-1 antagonist referral anakinra 100 mg SC daily OR rilonacept 320 mg SC loading then 160 mg weekly SC per agent — ≥2 recurrences despite optimal colchicine + NSAID (AIRTRIP (PMID 27825009) HR 0.10 vs placebo; RHAPSODY (PMID 33200890) HR 0.04 — Class IIa in ESC 2015 §Recurrent Pericarditis. Owner: cardio.pericarditis.core.v1 — referral only here.)

Non-pharmacologic actions:
- Cardiology pericarditis-clinic visit q4–8 wk during taper, then q3–6 mo for 1–2 yr (ESC 2015 §Long-term Surveillance)
- Activity progression: gradual return to baseline once CRP normal × 2 visits + symptom-free × 4 wk (ESC 2015 §Activity Restriction)
- Patient education: lifetime awareness of recurrence symptoms; medical-alert wallet card if on long-term IL-1 (immunosuppression)

AVOID / contraindication checks:
- Positive_pressure_ventilation_AVOID_pre_drain_drops_preload (ESC 2015 §Tamponade Management)
- Diuretics_AVOID_pre_drain_drops_preload (Spodick Circulation 2003)
- Nitrates_AVOID_pre_drain (Spodick Circulation 2003)
- NSAID_AVOID_uremic_or_post_MI_acute (Adler et al 2015)
- Type_A_dissection_avoid_full_drain (ESC 2015 §Aortic Dissection)

Monitoring

Regimen monitoring:
- continuous ECG during drainage (ESC 2015 §Pericardiocentesis Technique)
- art line BP pre and post (Adler et al 2015)
- echo post drain immediate then q12-24h (ESC 2015 Class I)
- fluid analysis cytology culture AFB ADA cell count (ESC 2015 §Pericardial Fluid Analysis)
- surveillance for re accumulation (Ristić EHJ 2014)

Setting (outpatient) monitoring:
- CRP q4–8 wk during taper; q3–6 mo after taper × 1 yr (ESC 2015)
- Echo annually if effusion was large at presentation; annually × 2 yr if effusive-constrictive pattern was suspected (Sagristà-Sauleda PMID 14749455)
- CBC + CMP q3 mo while on colchicine

Monitoring phase: Re-accumulation surveillance (echo q12–24h initially; ESC 2015 §Follow-up); fluid analysis (cytology, culture, AFB, ADA, cell count)

Disposition

Current setting: outpatient — Long-term surveillance for pericarditis recurrence + complete colchicine taper + transition to chronic pericarditis engine if recurrent (ESC 2015 §Long-term Follow-up; Khandaker Mayo Clin Proc 2010 PMID 20511488)

Disposition criteria:
- Recurrence-free × 12 mo off colchicine + normal CRP + normal echo → discharge to PCP with annual cardiology check (ESC 2015 §Discharge from Specialty Care)

Escalation triggers (move to higher acuity):
- Recurrence despite optimal therapy → transfer ownership to cardio.pericarditis.core.v1 + IL-1 escalation evaluation (AIRTRIP/RHAPSODY)
- New hemodynamic compromise → ED for emergent re-evaluation (ESC 2015 Class I — repeat tamponade pathway)
- Effusive-constrictive pattern persisting >3 mo → CMR + cardiothoracic referral for pericardiectomy evaluation (ESC 2015 Class IIa; Sagristà-Sauleda PMID 14749455)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 + Beck triad + echo confirms tamponade physiology (Spodick Circulation 2003; ESC 2015)
- [LIFE_THREATENING] Tamponade from Type A dissection / post-PCI/ablation / trauma / AC + post-procedure (ESC 2015 §Iatrogenic Tamponade)
- [SEVERE] Tamponade in known/new cancer with malignant cells on cytology (Ristić EHJ 2014)

Citations

- 2015 ESC Guidelines for the diagnosis and management of pericardial diseases (Adler Y et al, Eur Heart J 2015;36:2921-64, PMID 26320112) — remains current as of 2026-05-14; ESC 2026 update not yet announced. ICAP / CORP / CORP-2 / AIRTRIP / RHAPSODY anchor post-drainage anti-inflammatory + IL-1 escalation evidence base. Roy JAMA 2007 Rational Clinical Examination chapter (PMID 17456823) anchors physical exam likelihood ratios. [PMID:26320112](https://pubmed.ncbi.nlm.nih.gov/26320112/)
- Cited evidence (PMID 17456823) [PMID:17456823](https://pubmed.ncbi.nlm.nih.gov/17456823/)
- Cited evidence (PMID 23992557) [PMID:23992557](https://pubmed.ncbi.nlm.nih.gov/23992557/)
- Cited evidence (PMID 21873705) [PMID:21873705](https://pubmed.ncbi.nlm.nih.gov/21873705/)
- Cited evidence (PMID 24694983) [PMID:24694983](https://pubmed.ncbi.nlm.nih.gov/24694983/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 2015 ESC Guidelines for the diagnosis and management of pericardial diseases (Adler Y et al, Eur Heart J 2015;36:2921-64, PMID 26320112) — remains current as of 2026-05-14; ESC 2026 update not yet announced. ICAP / CORP / CORP-2 / AIRTRIP / RHAPSODY anchor post-drainage anti-inflammatory + IL-1 escalation evidence base. Roy JAMA 2007 Rational Clinical Examination chapter (PMID 17456823) anchors physical exam likelihood ratios. — PMID:26320112
  • Cited evidence (PMID 17456823) — PMID:17456823
  • Cited evidence (PMID 23992557) — PMID:23992557
  • Cited evidence (PMID 21873705) — PMID:21873705
  • Cited evidence (PMID 24694983) — PMID:24694983