Cardiac tamponade resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]; Ayokunle Olubaniyi, M.B,B.S [3]; Rim Halaby, M.D. [4]

Cardiac Tamponade Resident Survival Guide Microchapters
Overview
Causes
FIRE
Complete Diagnostic Approach
Treatment
Do's
Don'ts

Overview

Cardiac tamponade is a medical emergency resulting from the compression of the heart by accumulated fluid, pus, blood, or gas in the pericardial space. The symptoms and signs of cardiac tamponade depends on the etiology of the pericardial effusion and the rate of fluid accumulation. Beck's triad is typical in acute cardiac tamponade but is usually absent in subacute cases, where edema can be the primary presentation. Low-pressure tamponade occurs in patients with hypovolemia at diastolic pressures of 6 to 12 mm Hg and regional cardiac tamponade occurs when there is a loculated effusion compressing a specific cardiac chamber (often left side). Echocardiography is the primary diagnostic modality of choice and the treatment of cardiac tamponade is drainage of the pericardial fluid either by pericardiocentesis or surgical drainage.

Causes

Life Threatening Causes

Cardiac tamponade is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Acute Cardiac Tamponade

• Idiopathic
• Ascending aortic dissection
• Iatrogenic (central line insertion, pacemaker insertion, coronary interventions, myocardial biopsy)
• Penetrating trauma
• Myocardial infarction

Subacute Cardiac Tamponade

• Idiopathic
• Collagen vascular diseases
• Malignancy (breast cancer, Kaposi's sarcoma, lung cancer, lymphomas)
• Medications (cyclosporine, anticoagulants, thrombolytics)
• Pericarditis
• Radiation
• Tuberculosis
• Uremia

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in red color signify that an urgent management is needed.

Abbreviations: FFP: Fresh frozen plasma; IVC: Inferior vena cava; INR: International normalized ratio; LV: Left ventricle; RA: Right atrium; RV: Right ventricle

Identify cardinal findings that increase the pretest probability of cardiac tamponade: ❑ Dyspnea on exertion or tachypnea that progresses to air hunger at rest ❑ Tachycardia (may be masked in uremia or hypothyroidism) ❑ Symptoms of shock (altered mental status, cold extremities, peripheral cyanosis) ❑ Absolute or relative hypotension ❑ Pulsus paradoxus (↓ SBP of ≥10 mm Hg during inspiration; may be masked in hypotension, pericardial adhesions, right ventricular hypertrophy, aortic regurgitation, or atrial septal defect) ❑ Jugular venous distention (may be masked in hypovolemia) ❑ Pericardial rub

Order urgent echocardiography: Diagnosis of cardiac tamponade is suggested by: ❑ Collapse of cardiac chamber: ❑ Diastolic collapse of the right atrium (RA) ❑ Diastolic collapse of the right ventricle (RV) ❑ Left sided chamber collapse ❑ Respiratory variation in chamber size: ❑ RV↑ and LV↓ with inspiration ❑ Respiratory variation in transvalvular velocities ❑ ↑ tricuspid and pulmonic with inspiration ❑ ↓ mitral and aortic with inspiration ❑ Dilated IVC and hepatic veins

Unstable (pericardial effusion pressure >15 mm Hg)

Stable (pericardial effusion pressure <10 mm Hg)

❑ Immediately transfer the patient to ICU ❑ Monitor vitals continuously ❑ Avoid positive pressure mechanical ventilation (it may further reduce cardiac filling) ❑ Carefully initiate volume replacement among patients with severe hypotension as it may exacerbate the cardiac tamponade ❑ Avoid diuretics because it may worsen the central venous pressure

❑ Proceed with the complete diagnostic approach below

❑ Urgent removal of pericardial fluid: ❑ Assess for coagulopathy or the intake of antithrombotic medications before choosing the modality of drainage ❑ Discontinue anticoagulation drugs and initiate FFP if there is high INR

Emergent pericardiocentesis: ❑ Indication: ❑ Choose pericardiocentesis as a therapeutic option unless the patient has an indication for surgical drainage. ❑ When surgical drainage is indicated but the patient has severe hypotension prohibiting the induction of anesthesia, perform pericardiocentesis in the operating room before surgery. ❑ Myocardial rupture: Rescue pericardiocentesis may be done before surgical drainage ❑ Subxiphoid approach (most preferred) ❑ Avoid the subcostal approach if coagulopathy is present to prevent life-threatening hepatic injury ❑ Drain fluid < 1 L at a time (to prevent sudden decompression syndrome) ❑ Absolute contraindication: ❑ Aortic dissection ❑ Distorted anatomy due to prior surgery or radiation therapy ❑ Inaccessibility of the heart by percutaneous drainage ❑ Relative contraindication: ❑ Uncorrected coagulopathy ❑ Anticoagulant therapy ❑ Thrombocytopenia < 50,000/mm³ ❑ Small (< 1cm in echo), posterior and loculated effusion ❑ Severe pulmonary hypertension

Surgical pericardiectomy and drainage: ❑ Indications: ❑ Aortic dissection ❑ Distorted anatomy due to prior surgery or radiation therapy ❑ Inaccessibility of the heart by percutaneous drainage ❑ Also more appropriate for: ❑ Myocardial rupture ❑ Low volume of pericardial fluid (< 1 cm on echo) ❑ Loculated effusion posteriorly ❑ Reaccumulation after pericardiocentesis ❑ Traumatic hemopericardium and purulent pericarditis

Intensified renal dialysis: ❑ Indication: ❑ Cardiac tamponade due to uremia ❑ If not resolved by dialysis, pericardiocentesis should be attempted.

❑ After stabilization proceed with the complete diagnostic approach below

Complete Diagnostic Approach to Cardiac Tamponade

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Characterize the symptoms: ❑ Chest pain ❑ Cough ❑ Pleuritic pain ❑ Cyanosis ❑ Dysphagia ❑ Anorexia ❑ Dyspnea ❑ Fatigue ❑ Orthopnea ❑ Fever ❑ Near syncope ❑ Loss of consciousness ❑ Cool extremities ❑ Peripheral cyanosis ❑ Peripheral edema ❑ Low urine output

Obtain a detailed history: ❑ Time course of illness ❑ Acute: These patients tolerate a smaller volume of fluid ❑ Subacute: These patients can tolerate a larger volume of fluid ❑ Concurrent medical illness ❑ Hypothyroidism ❑ Systemic lupus erythematosus ❑ Collagen vascular diseases ❑ Malignancy ❑ Kidney failure ❑ Medications ❑ Trauma ❑ Radiation therapy ❑ Recent cardiac therapeutic procedures ❑ Recent myocardial infarction ❑ History or risk factors of tuberculosis

Examine the patient: Vital signs: ❑ Pulse ❑ Tachycardia (typical) ❑ Bradycardia (in hypothyroidism and uremia) ❑ Blood pressure ❑ Hypotension (typical) ❑ Pulsus paradoxus (reduction in systolic blood pressure by ≥ 10 mmHg during inspiration) ❑ Respiratory rate ❑ Tachypnea ❑ Temperature ❑ Fever (suggestive of infectious or inflammatory etiology) ❑ Cardiovascular system ❑ Jugular vein distention ❑ Distant (muffled) heart sounds ❑ Pericardial friction rub ❑ Peripheral edema

Consider alternative diagnoses: ❑ For acute chest pain and hypotension ❑ Myocardial infarction ❑ Pulmonary embolism ❑ For the subacute symptoms ❑ Congestive heart failure ❑ Constrictive pericarditis ❑ Liver diseases ❑ For pulsus paradoxus ❑ Chronic bronchitis ❑ Emphysema ❑ Pneumothorax ❑ Pulmonary embolism

Order tests: (Urgent) ❑ EKG ❑ Sinus tachycardia ❑ Electrical alternans ❑ Low QRS voltages (suggestive of pericardidial effusion) ❑ Electromechanical dissociation ❑ Chest X-ray ❑ Enlarged cardiac silhouette (if the pericardial fluid is at least 200 mL) ❑ Clear lung fields ❑ 2-D and doppler echocardiography ❑ Location of the pericardial effusion ❑ Circumferential ❑ Loculated ❑ Anterior location is optimal for pericardiocentesis and should be > 1 cm ❑ Posterior location cannot be drained by pericardiocentesis ❑ Accesibility of the pericardial effusion ❑ Collapse of the cardiac chambers ❑ Transvalvular flow variation with respiration ❑ Dilation of the inferior vena cava ❑ Elevated ejection fraction Consider additional tests, if necessary: ❑ Cardiac MRI when echocardiography is inconclusive and to quantitate pericardial thickness ❑ Cardiac catheterization to measure filling pressures and to identify patients with an effusive / constrictive physiology

Treatment

Shown below is an algorithm depicting the management of cardiac tamponade.

Does the patient has any signs of hemodynamic instability? ❑ Hypotension ❑ Cold extremities ❑ Peripheral cyanosis ❑ Altered mental status

Yes

No

Initiate resuscitative measures: ❑ Transfer the patient to ICU ❑ Connect to ECG monitor ❑ Monitor vitals continuously ❑ Avoid positive pressure mechanical ventilation (it may further reduce cardiac filling) ❑ Carefully initiate volume replacement among patients with severe hypotension as it may exacerbate the cardiac tamponade ❑ Avoid diuretics because it may worsen the central venous pressure

Initiate resuscitative measures: ❑ Transfer the patient to ICU ❑ Administer O2 ❑ Establish 2 wide bore IV access ❑ Connect to ECG monitor ❑ Monitor vitals continuously

Drainage of the pericardial fluid

❑ Repeated echocardiographic monitoring ❑ Drainage of pericardial fluid if symptoms worsen or an increase in the effusion

Does the patient have any of the following? ❑ Low volume of pericardial fluid (< 1 cm on echo) ❑ Loculated effusion posteriorly ❑ Distorted anatomy due to prior surgery or radiation therapy ❑ Inaccessibility of the heart by percutaneous drainage ❑ Aortic dissection ❑ Myocardial rupture

No

Yes

Pericardiocentesis: ❑ Subxiphoid approach (most preferred) ❑ Avoid the subcostal approach if coagulopathy is present to prevent life-threatening hepatic injury ❑ Drain fluid < 1 L at a time (to prevent sudden decompression syndrome) ❑ Relative contraindication: ❑ Uncorrected coagulopathy ❑ Anticoagulant therapy ❑ Thrombocytopenia < 50,000/mm³ ❑ Small (< 1cm in echo), posterior and loculated effusion ❑ Severe pulmonary hypertension

❑ Surgical drainage

Send the pericardial fluid for analysis: ❑ Gram stain ❑ Culture ❑ Cytology ❑ AFB stain & mycobacteria culture ❑ Polymerase chain reaction for CMV

❑ Monitor vital signs continuously or frequently to assure there are no signs of reaccumulation (hypotension, tachycardia, pulsus) ❑ Monitor fluid drainage if a drain is left in. Once there is very little drainage, the drain can be removed. ❑ Monitor cardiac telemetry for arrhythmias ❑ Determine and treat the underlying cause ❑ Do not leave the pericardial fluid drainage catheter in place for > 3 days ❑ Repeat echocardiography before discharge ❑ Monitor the patient for complications ❑ Left ventricular failure ❑ Pulmonary edema ❑ Pneumothorax ❑ Arrhythmias ❑ Perforation of cardiac chambers (most often the right ventricle which may require repair) ❑ Hemothorax

Do's

Pericardiocentesis

• Indications for therapeutic pericardiocentesis

• Hemodynamic compromise and cardiac tamponade in patients with pericardial effusions (Class I)
• Effusions >20 mm in echocardiography in diastole (Class IIa)
• Large chronic effusions resistant to dialysis (Class IIa)

• Indications for diagnostic pericardiocentesis

• If additional procedures are available (e.g., pericardial fluid and tissue analyses, pericardioscopy, and epicardial/pericardial biopsy) which could reveal the etiology of the disease and permit further causative therapy (Class IIa)
• Suspected neoplastic effusion without tamponade (Class IIa)

• Absolute contraindications for pericardiocentesis

• Aortic dissection

• Relative contraindications for pericardiocentesis

• Uncorrected coagulopathy
• Anticoagulant therapy
• Thrombocytopenia <50,000 per mm3
• Small, posterior, and loculated effusions

Dont's

• The use of inotropic agents for hemodynamic support should not be a substitute or cause a delay to pericadiocentesis.
• Avoid the use of beta blockers in order to preserve the compensatory adrenergic response to pericardial effusion which include tachycardia and increased contractility.
• Carefully assess the use of diuretics in patients presenting with edema and low urinary output.