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

Cardiac tamponade is a medical emergency characterized by a slow or rapid compression of the heart by accumulated fluid, pus, blood, clots, or gas in the pericardium. 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. Cardiac tamponade is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Acute Cardiac Tamponade

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

Subacute Cardiac Tamponade

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

Management

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 ❑ Renal failure ❑ 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) ♦ Beck's triad - Low arterial blood pressure (hypotension), distant (muffled) heart sounds & distended neck veins (↑JVP)

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 ❑ Serum ANA/RF (for SLE) ❑ Cardiac catheterization, if necessary

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

Catheter pericardiocentensis with Echo-guidance (preferred for hemodynamically unstable patients)

Surgical drainage

Pericardial fluid analysis & treatment ❑ Gram stain, culture ❑ Cytology ❑ AFB stain & mycobacteria culture ❑ Polymerase chain reaction - CMV ❑ Initiate treament of underlying diseases

Manage complications ❑ Acute left ventricular failure + pulmonary edema ❑ Pneumothorax ❑ Ventricular arrhythmias ❑ Perforation of cardiac chambers ❑ Hemothorax

Monitoring ❑ Continuous telemetry ❑ Frequent vitals ❑ Daily monitoring of: ♦ Patency of the catheter ♦ Rate of drainage Note Leave catheter in situ for 24 - 48 hours or when the volume of drainage is <25 ml/day

Surgical Drainage

Consider surgical drainage in the following situations:

• Loculated pericardial effusions
• Recurrent effusion after prior drainage
• Presence of coagulopathy
• When pericardial biopsy is required to make a diagnosis of the underlying cause

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. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps in the making a diagnosis of cardiac tamponade. Pulsus paradoxus is the reduction in systolic blood pressure by ≥ 10 mmHg during inspiration.
• 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.
• Consider pericardiocentesis in all cases except aortic dissection or myocardial rupture, in which removal of fluid should be done in preparation for a surgical repair.

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.
• Avoid the use of beta blockers in order to preserve the compensatory adrenergic response to pericardial effusion which include tachycardia and increased contractility.