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]

Definition

Cardiac tamponade is a medical emergency characterized by a slow or rapid compression of the heart by accumulated fluid, pus, blood, clots, or gas in the pericardium.[1] It is suspected based on history, physical examination, and chest imaging findings, but it is confirmed based on the clinical response observed during or post-pericardial fluid drainage.

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

 
 
Characterize the symptoms:
Chest painCough
CyanosisDysphagia
DyspneaFatigue
FeverNear syncope
OrthopneaPeripheral edema

Or as symptoms of the following complications

Renal failure
Shock liverMesenteric ischemia
 
 
 
 
 
 
 
 
 
 
Patient evaluation:

Obtain a detailed history:
♦ Time course of illness
♦ Concurrent medical illness - hypothyroidism, systemic lupus erythematosus
♦ Trauma
♦ Radiation therapy
♦ Recent cardiac therapeutic procedures
♦ Recent myocardial infarction


Examine the patient:
❑ General- distended neck veins (↑JVP)
❑ Vitals
Tachycardia, tachypnea, hypotension
❑ Cardiopulmonary
♦ Clear lungs
♦ Distant (muffled) heart sounds
♦ Pericardial friction rub
❑ Limbs - peripheral edema
Note
♦ Measure BP and response to inspiration (pulsus paradoxus)
Bradycardia (especially in uremia or hypothyroidism)
Beck's triad - Low arterial blood pressure (hypotension), distant (muffled) heart sounds & distended neck veins (↑JVP)[2]
 
 
 
 
 
 
 
 
 
 
 
 
Emergent therapy
❑ Pulse oximetry
❑ Administer oxygen, if required
❑ Large bore IV lines
❑ Consult to ICU
❑ Fluid rescuscitation (blood, plasma, dextran or saline)[3]
or inotropic support (dobutamine, dopamine)
 
 
 
 
 
 
 
 
 
 
 
Urgent Labs:
EKG
Sinus tachycardia, electrical alternans, low QRS voltages
❑ Chest X-ray
♦ Enlarged cardiac silhouette
♦ clear lung fields
Echocardiography
Pericardial effusion
♦ Cardiac chamber collapse (right atrium and ventricle)
♦ Flow variation
♦ Dilation of IVC
CBC
Electrolytes
BUN
Creatinine
Consider additional tests, if necessary:
CT, cardiac MRI - when echo is inconclusive
❑ Thyroid function
❑ Serum ANA/RF (for SLE)
Cardiac catheterization, if necessary
 
 
 
 
 
 
 
 
 
 
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

  • Always suspect cardiac tamponade in any patient presenting with hypotension, tachycardia and distended neck veins (or elevated jugular venous pressure).
  • Always measure pulsus paradoxus whenever you suspect cardiac tamponade. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps in the making a diagnosis of cardiac tamponade.[4] Pulsus paradoxus is the reduction in systolic blood pressure by ≥ 10 mmHg during inspiration.
  • Consider the intrapericardial pressure more than the volume of the pericardial fluid in the management of cardiac tamponade.
  • The drainage of pericardial effusion should be gradual and slow to avoid the precipitation of pulmonary edema.
  • Echocardiography is the primary modality of choice, considering its high specificity and sensitivity, low cost and lack of radiation. CT and cardiac MRI are indicated when echocardiography is inconclusive.[5]
  • Consider 2D and doppler echocardiography prior to discharge to confirm total removal or detect reaccumulation of pericardial fluid.
  • Consider pericardiocentesis in all cases except aortic dissection or myocardial rupture, in which removal of fluid should be done in preparation for a surgical repair.

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.[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. 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. Sternbach, G.; Beck, C. "Claude Beck: cardiac compression triads". J Emerg Med. 6 (5): 417–9. PMID 3066820.
  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. 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)
  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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