Q: What is the ‘Rule of 20s’ in cardiac tamponade?
Answer: Although nothing is hard and fast in clinical medicine, if the following five 20s are present on clinical exam, it speaks of cardiac tamponade proved otherwise.
- CVP more than 20 cm H2O
- HR increases more than 20 beats/minute
- Pulsus paradoxes more than 20
- SBP decreased by more than 20 mmHg and
- Pulse pressure less than 20
Some students/intensivists may also like another 'rule of 20s' related to Pulmonary Artery Catheter insertion.
- Right atrium (or SVC) should be entered within 20 cm of the skin
- Right ventricle should be entered within 40 cm of the skin
- Pulmonary artery should be entered within 60 cm of the skin
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Further reading:
1. Ariyarajah V, Spodick DH. Cardiac tamponade revisited: a postmortem look at a cautionary case. Tex Heart Inst J. 2007;34(3):347-51. PMID: 17948086; PMCID: PMC1995065.
2. Curtiss EI, Reddy PS, Uretsky BF, Cecchetti AA. Pulsus paradoxus: definition and relation to the severity of cardiac tamponade. Am Heart J. 1988 Feb;115(2):391-8. doi: 10.1016/0002-8703(88)90487-5. PMID: 3341174.
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