Cardiac tamponade resident survival guide

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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]

Definition

Cardiac tamponade is a medical emergency resulting from the compression of the heart by accumulated fluid, pus, blood, or gas in the pericardial space.[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

Shown below is an algorithm depicting the management of patient with cardiac tamponade.[1][2][3]

 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history:

❑ Time course of illness

❑ Acute
❑ Subacute

❑ 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 pericarditis)
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

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

Consider additional tests, if necessary:

CT (when echocardiography is inconclusive)
❑ Cardiac MRI (when echocardiography is inconclusive)
Cardiac catheterization
 
 
 
 
 
 
 
 
 
 
When cardiac tamponade is confirmed, the patient needs drainage of the pericardial fluid
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following?

❑ Low volume of pericardial fluid
❑ Loculated effusion posteriorly
❑ Inaccessibility of the heart by percutaneous drainage
Aortic dissection
Myocardial rupture

 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
Catheter pericardiocentensis with echo-guidance
 
Surgical drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
Send the pericardial fluid for analysis:
Gram stain
culture
Cytology
❑ AFB stain & mycobacteria culture
Polymerase chain reaction for CMV
 
 
 
 
 
 
 
 

❑ Monitor vital signs frequently
❑ Determine and treat the underlying cause
❑ Repeat echocardiography before discharge
❑ Monitor the patient for complications

❑ Acute left ventricular failure
Pulmonary edema
Pneumothorax
Arrhythmias
❑ Perforation of cardiac chambers
Hemothorax
 

Do's

  • 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]
  • When surgical drainage is indicated but the patient has severe hypotension prohibiting the induction of anesthesia, perform pericardiocentesis in the operating room before surgery.[3]
  • 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]

Dont's

  • Never delay treatment whenever you suspect cardiac tamponade.
  • 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.[3]
  • Do not routinely initiate IV volume replacement because it may exacerbate the cardiac tamponade. Carefully initiate volume replacement among patients with severe hypotension.[3]
  • 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.[6]
  • 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 1.4 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 2.4 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. 3.0 3.1 3.2 3.3 3.4 3.5 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.
  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. 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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