In this episode of Hospital Medicine Unplugged, we cut through pericardial effusion in the inpatient setting—spot it fast with TTE, act early on tamponade, spare procedures when safe, and tailor to cause.

We open with the do-firsts: focused history/exam (dyspnea, chest pressure/fullness, pulsus paradoxus), ECG, CRP/ESR, CBC/chemistry ± troponin if myopericarditis suspected. TTE is first-line to confirm effusion, size it, and look for tamponade physiology (RA/RV diastolic collapse, plethoric IVC, respiratory inflow variation). If TTE is inconclusive, use CMR/CCT/TEE selectively for complex/loculated effusions or to chase secondary causes—routine CMR/CCT for tamponade assessment isn’t recommended.

Call tamponade when the clinical picture and echo line up; remember the physiology: rate of accumulation beats absolute volume—rapid fluid overwhelms pericardial compliance.

Action when it tips:
• Cardiac tamponade or hemodynamic compromise → urgent pericardiocentesis, ideally echo-guided. Gentle IV fluids while prepping; avoid PPV if possible.
• Send fluid: cell count, protein/glucose/LDH, Gram & cultures, AFB/TB PCR, cytology ± triglycerides if chylous suspected.

If there’s no tamponade:
• Don’t tap by default. Observe with serial TTE for moderate/large effusions.
• Recurrent large effusions or recurrence after prior tap? Pericardial window is reasonable—lower reintervention vs repeat taps but higher procedural risk; pick based on etiology, recurrence risk, and patient goals.

When effusion rides with acute pericarditis, build the anti-inflammatory backbone:
• NSAID (e.g., ibuprofen 600–800 mg q6–8h or aspirin 650–1000 mg q8h) + colchicine 0.5–0.6 mg BID (>70 kg) or QD (≤70 kg) for 3 months; add PPI.
• Reserve corticosteroids (e.g., pred 0.2–0.5 mg/kg/day) for refractory or contraindications to NSAID/colchicine; taper slowly, CRP-guided.

Etiology plays—treat the cause:
• TB: full RIPE; consider steroids if constrictive/inflammatory phenotype.
• Uremia: intensify dialysis; drain if tamponade/large symptomatic.
• Malignancy: drain for symptoms/diagnosis; high recurrence → window or extended catheter drainage; consider intrapericardial therapy in select cases.
• Post–cardiac injury/post-op: standard NSAID+colchicine; window for loculated/recurrent.

Who stays and how we watch:
• Large or symptomatic but stable: close inpatient monitoring, daily clinical checks, frequent TTE (daily or q1–2 days).
• Small-to-moderate, stable: outcome is usually benign—watchful waiting with interval TTE; educate on red flags (worsening dyspnea, presyncope, hypotension).
• Chronic, large, asymptomatic, idiopathic: watchful waiting is often safe; consider drainage if >3 months or new symptoms/inflammation—evidence is limited, so individualize.

Pearls & pitfalls you don’t want to meet:
• Don’t chase every effusion with a needle—match intervention to hemodynamics and suspected cause.
• Early steroids in pericarditis → higher recurrence; use as a bridge only when needed.
• Light’s criteria don’t apply to pericardial fluid—normal fluid is exudative.
• Cytology can be falsely negative—a benign result doesn’t exclude malignancy; keep hunting if suspicion is high.
• Trend CRP to steer NSAID taper and to judge inflammation quieting down.

We close with the inpatient bundle that sticks: (1) TTE first ± selective CMR/CCT/TEE; (2) tamponade pathway (STAT echo → urgent echo-guided pericardiocentesis → full fluid studies); (3) no routine taps for stable effusions; (4) NSAID + colchicine for inflammatory cases, steroid-sparing strategy; (5) serial TTE for moderate/large effusions; (6) etiology-specific tracks (TB, uremia, malignancy, post-op) with multidisciplinary consults; (7) shared decision-making for pericardial window in recurrent/malignant disease.

Bottom line—imaging-led and risk-stratified: use TTE to steer, drain when unstable, treat the cause, and surveil the rest without over-proceduring.