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: IVC: Inferior vena cava; LV: Left ventricle; RA: Right atrium; RV: Right ventricle

Identify cardinal findings that increase the pretest probability of cardiac tamponade: ❑ Sinus tachycardia ❑ Elevated jugular venous pressure ❑ Pulsus paradoxus ❑ 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

❑ Proceed with the complete diagnostic approach below

❑ Urgent removal of pericardial fluid

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. ❑ Contraindication: ❑ Absolute: Stable vital signs ❑ Relative: Severe pulmonary hypertension, bleeding diathesis

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

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

Shown below is an algorithm depicting the diagnostic approach to cardiac tamponade.

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 ❑ 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

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 diagnostic approach to cardiac tamponade.

Drainage of the pericardial fluid

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

❑ Pericardiocentensis

❑ 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 ❑ 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

• 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 ventricular hypertrophy without pulmonary hypertension
  • Severe aortic regurgitation
  • Atrial septal defect

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

• Consider echocardiography as the primary diagnostic modality of choice due to its high specificity and sensitivity, low cost and lack of radiation. Order a CT scan or a cardiac MRI when echocardiography is inconclusive.

• Assess for the presence of coagulopathy or the intake of antithrombotic medications before choosing the modality of drainage of the pericardial fluid.

• Make sure the drainage of pericardial effusion is gradual and slow to avoid the precipitation of pulmonary edema.

Dont's

• Never delay treatment whenever cardiac tamponade is suspected.
• Avoid diuretics because it may worsen the central venous pressure. Carefully assess the use of diuretics in patients presenting with edema and low urinary output.
• Do not routinely initiate IV volume replacement because it may exacerbate the cardiac tamponade. Carefully initiate volume replacement among patients with severe hypotension.
• Avoid leaving a pericardial fluid drainage catheter in place 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.