Cardiac tamponade resident survival guide: Difference between revisions

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❑ Peripheral edema </div>}}
❑ Peripheral edema </div>}}
{{familytree | | | |!| | | | |}}
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{{familytree | | | B03 | | B03= <div style="float: left; text-align: left; width: 35em; padding:1em;"> '''Consider alternative diagnoses for pulsus paradoxus:''' <br>
{{familytree | | | B03 | | B03= <div style="float: left; text-align: left; width: 35em; padding:1em;"> '''Consider alternative diagnoses:''' <br>
❑ [[Bronchitis|Chronic bronchitis]] <br>
❑ For acute chest pain and hypotension
❑ [[Emphysema]] <br>
:❑ [[Myocardial infarction]]
❑ [[Pneumothorax]] <br>
:❑ [[Pulmonary embolism]]
❑ [[Pulmonary embolism]] </div> }}
❑ For the subacute symptoms
:❑ [[Congestive heart failure]]
:❑ [[Constrictive pericarditis]]
:❑ [[Liver diseases]]
❑ For pulsus paradoxus <br>
:❑ [[Bronchitis|Chronic bronchitis]] <br>
:❑ [[Emphysema]] <br>
:❑ [[Pneumothorax]] <br>
:❑ [[Pulmonary embolism]] </div> }}
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{{familytree | | | C01 | | |C01=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''Begin emergent therapy:'''
{{familytree | | | C01 | | |C01=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''Begin emergent therapy:'''

Revision as of 19:05, 1 March 2014

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 the compression of the heart by accumulated fluid, pus, blood, clots, or gas in the pericardium.[1]

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

Subacute Cardiac Tamponade

Management

 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history:

❑ Time course of illness
❑ Concurrent medical illness

Hypothyroidism
Systemic lupus erythematosus
Collagen vascular diseases
Malignancy
Kidney failure

MedicationsTrauma
❑ Radiation therapy
❑ Recent cardiac therapeutic procedures
❑ Recent myocardial infarction
❑ History or risk factors of tuberculosis

 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ Vital signs

Tachycardia (typical)
Bradycardia (in hypothyroidism and uremia)
Tachypnea
Hypotension (typical)

Pulsus paradoxus
Jugular vein distention
❑ Cardiopulmonary system

❑ Clear lungs
❑ 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
 
 
 
 
 
 
 
 
 
 
 
 
Begin emergent therapy:

❑ Place and monitor pulse oximetry
❑ Administer oxygen, if required
❑ Insert large bore IV lines
❑ Transfer to ICU

❑ Resuscitate the patient (blood, plasma, dextran or saline)[3]
or inotropic support (dobutamine, dopamine)
 
 
 
 
 
 
 
 
 
 
 
Order labs: (Urgent)

EKG

Sinus tachycardia
Electrical alternans
❑ Low QRS voltages (suggestive of pericarditis)
Electromechanical dissociation

❑ Chest X-ray

❑ Enlarged cardiac silhouette (if the pericardial fluid is at least 200 mL)
❑ Clear lung fields

Doppler echocardiography

❑ Circumferential pericardial effusion
❑ Collapse of the cardiac chambers
❑ Transvalvular flow variation with respiration
❑ Dilation of IVC
❑ Elevated ejection fraction[1]

CBC
Electrolytes
BUN
Creatinine


Consider additional tests, if necessary:
❑ Thyroid function
❑ Serum ANA, rheumatoid factor
CT (when echocardiography is inconclusive)
❑ Cardiac MRI (when echocardiography is inconclusive)
Cardiac catheterization
 
 
 
 
 
 
 
 
 
 
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

  • Suspect an infectious or inflammatory etiology when fever is present.[2]
  • Make sure the drainage of pericardial effusion is gradual and slow to avoid the precipitation of pulmonary edema.
  • Consider echocardiography as the primary modality of choice due to its high specificity and sensitivity, low cost and lack of radiation. Order s CT scan or a cardiac MRI when echocardiography is inconclusive.[5]
  • Consider 2D and doppler echocardiography prior to discharging the p[atient to confirm total removal or detect reaccumulation of pericardial fluid.
  • When surgical drainage is indicated but the patient has severe hypotension prohibiting the induction of anesthesia, perform pericardiocentesis in the operating room before surgery.[6]
  • In the case of subclinical uremia, manage the patient by an intensified renal dialysis. If cardiac tamponade is not resolved by dialysis, pericardiocentesis should be attempted.[1]

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.[7]
  • 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.

References

  1. 1.0 1.1 1.2 1.3 Spodick, DH. (2003). "Acute cardiac tamponade". N Engl J Med. 349 (7): 684–90. doi:10.1056/NEJMra022643. PMID 12917306. Unknown parameter |month= ignored (help)
  2. 2.0 2.1 2.2 2.3 Roy, CL.; Minor, MA.; Brookhart, MA.; Choudhry, NK. (2007). "Does this patient with a pericardial effusion have cardiac tamponade?". JAMA. 297 (16): 1810–8. doi:10.1001/jama.297.16.1810. PMID 17456823. Unknown parameter |month= ignored (help)
  3. Kerber, RE.; Gascho, JA.; Litchfield, R.; Wolfson, P.; Ott, D.; Pandian, NG. (1982). "Hemodynamic effects of volume expansion and nitroprusside compared with pericardiocentesis in patients with acute cardiac tamponade". N Engl J Med. 307 (15): 929–31. doi:10.1056/NEJM198210073071506. PMID 7110273. Unknown parameter |month= ignored (help)
  4. Sternbach, G.; Beck, C. "Claude Beck: cardiac compression triads". J Emerg Med. 6 (5): 417–9. PMID 3066820.
  5. Maisch, B.; Seferović, PM.; Ristić, AD.; Erbel, R.; Rienmüller, R.; Adler, Y.; Tomkowski, WZ.; Thiene, G.; Yacoub, MH. (2004). "Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology". Eur Heart J. 25 (7): 587–610. doi:10.1016/j.ehj.2004.02.002. PMID 15120056. Unknown parameter |month= ignored (help)
  6. 6.0 6.1 Schiavone WA (2013). "Cardiac tamponade: 12 pearls in diagnosis and management". Cleve Clin J Med. 80 (2): 109–16. doi:10.3949/ccjm.80a.12052. PMID 23376916.
  7. Little, WC.; Freeman, GL. (2006). "Pericardial disease". Circulation. 113 (12): 1622–32. doi:10.1161/CIRCULATIONAHA.105.561514. PMID 16567581. Unknown parameter |month= ignored (help)

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