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]

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.

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

Shown below is an algorithm depicting the management of patient with 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 ❑ 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 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 acute 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 subacute cases. Suspect acute cardiac tamponade when there is sudden hypotension, and consider subacute cardiac tamponade when edema is present.

• 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 ventricle hypertrophy without pulmonary hypertension
  • Severe aortic regurgitation
  • Atrial septal 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 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.

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.
• Do not routinely initiate IV volume replacement because it may exacerbate the cardiac tamponade. Carefully initiate volume replacement among patients with severe hypotension.
• 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.