HUGE thanks to Dr. Phan for an incredible noon report today! He presented a case of a young woman with a history of metastatic cancer who presented with chest pain and shortness of breath, found to have a pericardial effusion with concern of tamponade physiology. In the age of echocardiography, it is easy to lose our pulsus paradoxus skills, but this is an important maneuver that should stay in our physical exam repertoire!
Pulsus paradoxus is a phenomenon that was first described in 1873 by German physician Dr. Adolf Kussmaul (yes, the same Kussmaul as Kussmaul’s sign with JVP and Kussmaul breathing in DKA). It is an exaggeration of the normal inspiratory decrease in systolic blood pressure, which is less than 10 mm Hg.
JAMA published an excellent article on this in the Rational Clinical Exam Series – “Does This Patient With a Pericardial Effusion Have Cardiac Tamponade?”, from which the diagram below is taken. It showed up to 98% sensitivity for cardiac tamponade, and 82% pooled sensitivity.
Watch this helpful Stanford video for assistance in honing your technique: https://www.youtube.com/watch?v=jTsjCZ9QxW8