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]

Definition

This is a medical emergency which involves a slow or rapid compression of the heart due to the accumulation of fluid, pus, blood, clots, or gas in the pericardium, as a result of effusion, trauma, or rupture of the heart. It is suspected based on history, physical examination, and chest imaging findings, but it is confirmed based on the clinical response observed during or post-pericardial fluid drainage.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Acute Cardiac Tamponade

• Ascending aortic dissection
• Iatrogenic - central line insertion, pacemaker insertion, coronary interventions, myocardial biopsy
• Penetrating trauma
• Post myocardial infarction treatments - heparin, thrombolytics

Subacute Cardiac Tamponade

• Collagen vascular diseases
• Idiopathic
• Malignancy - breast, Kaposi's sarcoma, lung, lymphomas
• Pericarditis

Viral - coxsachie, echo, CMV

Bacterial - pneumococcus, streptococcus, staphylococcus

Fungal - blastomyces, cryptococcus, histoplasma, pneumocystis carinii

Tuberculous

• Radiation
• Uremia

Management

Characterize the symptoms: ❑ Chest pain ❑ Cough ❑ Cyanosis ❑ Dysphagia ❑ Dyspnea ❑ Fatigue ❑ Fever ❑ Near syncope ❑ Orthopnea ❑ Peripheral edema Or as a feature of a complication ❑ Renal failure ❑ Abdominal plethora ❑ Shock liver ❑ Mesenteric ischemia

Patient evaluation: ❑ Obtain a detailed history: ♦ Time course of illness ♦ Concurrent medical illness - hypothyroidism, systemic lupus erythematosus ♦ Trauma ♦ Radiation therapy ♦ Recent cardiac therapeutic procedures ♦ Recent myocardial infarction ❑ Examine the patient: ❑ General- distended neck veins (↑JVP) ❑ Vitals ♦ Tachycardia, tachypnea, hypotension ❑ Cardiopulmonary ♦ Clear lungs ♦ Distant (muffled) heart sounds ♦ Pericardial friction rub ❑ Limbs - peripheral edema Note ♦ Measure BP and response to inspiration (pulsus paradoxus) ♦ Bradycardia (especially in uremia or hypothyroidism)

Emergent therapy ❑ Pulse oximetry ❑ Administer oxygen, if required ❑ Large bore IV lines ❑ Consult to ICU ❑ Fluid rescuscitation (blood, plasma, dextran or saline) or inotropic support (dobutamine, dopamine)

Urgent Labs: ❑ EKG ♦ Sinus tachycardia, electrical alternans, low QRS voltages ❑ Chest X-ray ♦ Enlarged cardiac silhouette ♦ clear lung fields ❑ Echocardiography ♦ Pericardial effusion ♦ Cardiac chamber collapse (right atrium and ventricle) ♦ Flow variation ♦ Dilation of IVC ❑ CBC ❑ Electrolytes ❑ BUN ❑ Creatinine Consider additional tests, if necessary: ❑ CT, cardiac MRI - when echo is inconclusive ❑ Thyroid function ❑ Serun ANA (SLE)

Choice of treatment Based on: ❑ Echo findings ❑ Size and location of fluid ❑ Etiology or precipitating events ❑ Risk of procedure ❑ Hemodynamic status

Pre-procedural preparation ❑ Echo to determine the size, location, and to assess if effusion is loculated or not ❑ PT/PTT/INR ❑ Reverse all anticoagulation ❑ Consult to cardiac catheterization lab

Dos

• Always suspect cardiac tamponade in any patient presenting with hypotension, tachycardia and distended neck veins (or elevated jugular venous pressure).
• Always measure pulsus paradoxus whenever you suspect cardiac tamponade.
• Consider the intrapericardial pressure more than the volume of the pericardial fluid in the management of cardiac tamponade.
• The drainage of pericardial effusion should be gradual and slow to avoid the precipitation of pulmonary edema.
• Echocardiography is the primary modality of choice, considering its high specificity and sensitivity, low cost and lack of radiation. CT and cardiac MRI are indicated when echocardiography is inconclusive.
• Consider 2D and doppler echocardiography prior to discharge to confirm total removal or detect reaccumulation of pericardial fluid.

Don'ts

• Never delay treatment whenever you suspect cardiac tamponade.
• Avoid diuretics because it may worsen the central venous pressure.
• Avoid placing pericardial fluid drainage catheter in situ for > 3 days.
• Avoid the subcostal approach of pericardiocentesis if coagulopathy is present. Iatrogenic injuries to the liver may be life-threatening.
• Avoid positive pressure mechanical ventilation. It may further reduce cardiac filling.
• The use of inotropic agents for hemodynamic support should not be a substitute or cause a delay to pericadiocentesis.