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

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

• 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

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 ❑ Low urine output

Obtain a detailed history: ❑ Time course of illness ❑ 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 ❑ 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) 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 ❑ 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 cardiac tamponade in any patient presenting with Beck's triad: hypotension, tachycardia and distended neck veins (or elevated jugular venous pressure). Beck's triad is typical in acute cardiac tamponade but is usually absent in chronic cases.

• Measure pulsus paradoxus whenever cardiac tamponade is suspected. Pulsus paradoxus is the reduction in systolic blood pressure by ≥ 10 mmHg during inspiration. Pulsus paradoxus can be absent among patients with cardiac tamponade in the following cases:
  • Severe hypotension
  • Pericardial adhesions
  • Stiffness in the left ventricle much more than that in the right ventricle
  • Right ventricule hypertrophy without pulmonary hypertension
  • Severe aortic regurgitation
  • Atrial septic defect

• Suspect an infectious or inflammatory etiology when fever is present.

• 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.

• Consider 2D and doppler echocardiography prior to discharging the p[atient to confirm total removal or detect reaccumulation of pericardial fluid.

• Consider surgical drainage in aortic dissection and myocardial rupture.

• When surgical drainage is indicated but the patient has severe hypotension prohibiting the induction of anesthesia, perform pericardiocentesis in the operating room before surgery.

• 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.

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.