Mr. Husain Nadaf, Tutor

1. CARDIAC
TAMPONADE
Guided by: Asst. Prof. Mr Amos Talsandekar
HOD Of Medical – Surgical Nursing
D.Y Patil College Of Nursing
Presented By: Husain K Nadaf
M.Sc Nursing 1st Year
Medical - Surgical Nursing

2. INTRODUCTION
• Pericardial effusion refers to the accumulation
of fluid in the pericardial sac. This occurrence
may accompany pericarditis, advanced HF,
metastatic carcinoma, cardiac surgery,trauma,
or nontraumatic hemorrhage.
• Normally, the pericardial sac contains less than
50 mL of fluid, which is needed to decrease
friction for the beating heart. An increasein
pericardial fluid raises the pressure within the
pericardial sac and compresses the heart. This
has the following effects:

3. CONTINUED….
• Increased right and left ventricular end-
diastolic pressures
• Decreased venous return
• Inability of the ventricles to distend adequately
and to fill
A rapidly developing effusion, however, can
stretch the pericardium to its maximum size
and, because of increased pericardial pressure
comprises these above effects

4. • The pericardial sac surrounds the heart and
normally contains only 10 to 20 mL of serous
fluid.
• The sudden accumulation of more fluid (as
little as 200 mL of fluid or blood) compresses
the heart and coronary arteries, compromising
diastolic filling and systolic emptying and
diminishing oxygen supply.
• The end result is decreased oxygen delivery
and poor tissue perfusion to all organs.

5. INCIDENCE
• The incidence of cardiac tamponade in the United
States is 2 cases per 10,000 population, and
approximately 2% of penetrating injuries lead to
cardiac tamponade.
• It is a potentially life-threatening condition,
needing emergency assessment and immediate
interventions.
• Some patients develop a more slowly
accumulating tamponade that collects over weeks
and months. If the fibrous pericardium gradually
has time to stretch, the pericardial space can
accommodate as much as 1 to 2 L of fluid before
the patient becomes acutely symptomatic

6. PHASES OF CARDIAC TAMPONADE
• Three phases of hemodynamic changes occur
with acute cardiac tamponade:-
Phase 1:-
• Accumulation of pericardial fluid leads to
increased ventricular stiffness, which requires a
higher filling pressure; left and right ventricular
filling pressures are higher than the
intrapericardial pressure during this phase.

7. CONTINUED
Phase 2:-
• As fluid accumulates, pericardial pressure
increases above the ventricular filling pressure;
cardiac output thereby is reduced.
Phase 3:-
• Decrease in cardiac output continues, due to
equilibration of pericardialand left ventricular
filling pressures

8. CAUSES
• Cardiac tamponade may have any of a variety
of etiologies.
• It can be caused by both blunt and penetrating
traumatic injuries.
• Iatrogenic injuries, such as those associated
with removal of epicardial pacing wires and
complications after cardiac catheterization and
insertion of central venous or pulmonary artery
catheters.

9. CONTINUED…
• Rupture of the ventricle after an acute
myocardial infarction or bleeding after cardiac
surgery can also lead to tamponade.
• Other causes include treatment with
anticoagulants, viral infections, pericarditis,
neoplasm’s, as well as collagen diseases such
as rheumatoid arthritis.

10. CLINICAL MANIFESTATIONS
• The patient with cardiac tamponade may report chest
pain and is often confused, anxious, and restless
Beck clinical manifestation
• As the compressionof the heart increases, there is
decreased cardiac output (CO), muffled heart sounds,
and narrowed pulse pressure.
• The patientdevelops tachypnea and tachycardia.
• Neck veins usually are markedly distended because
of increased jugular venous pressure
• Pulsusparadoxusis a decrease in systolic BP during
inspiration that is exaggerated in cardiac tamponade
• In a slow onset, dyspnea may be the only clinical
manifestation.

11. DIAGNOSTIC ASSESMENT
HISTORY COLLECTION:-
• The patient’s history may include surgery,
trauma, cardiac biopsy, and viral infection,
insertion of a transvenous pacing wire or
catheter, or myocardial infarction.
• Elicit a medication history to determine if the
patient is taking anticoagulants or any medicine
as(procainamide, hydralazine, minoxidil,
isoniazid, penicillin, methysergide, or
daunorubicin).
• Ask if the patient has renal failure, which can
lead to pericarditis and bleeding.

12. CONTINUED
PHYSICAL EXAMINATION:-
• The patient who has acute, rapid bleeding with
cardiac tamponade appears critically ill and in
shock The patient can be acutely hypovolemic
• Auscultate the heart, you may hear a
pericardial friction rub as a result of the heart
sounds may be muffled because of the
accumulation of fluid around the heart.
• Extended neck jugular veins & Beck signs

13. CONTINUED…
• Echocardiogram, which is an ultrasound of your
heart. It can detect whether the pericardium is
distended and if the ventricles have collapsed due
to low blood volume.
• Chest X-rays may show an enlarged, globe-shaped
heart if you have cardiac tamponade. Other
diagnostic tests may include:
• A Thoracic CT scan to look for fluid accumulation
in your chest or changes to your heart
• a Magnetic resonance angiogram to see how blood
is flowing through your heart
• An electrocardiogram to assess your heartbeat

14. MEDICAL MANAGEMENT
• Pericardiocentesis:-is usually performed for
pericardial effusion with acute cardiac
tamponade, purulent pericarditis, and suspected
neoplasm. Hemodynamic support for the
patient being prepared for the
pericardiocentesis may include administration
of volume expanders and inotropic agents (e.g.,
dopamine [Intropin]) and the discontinuation of
any anticoagulants.

15. CONTINUED…
• The procedure is performed rapidly and safely
using a percutaneous approach that is guided
by echocardiography.
• A needle is inserted into the pericardial space
to remove fluid for analysis and to relieve
cardiac pressure.

16. PHARMACOLOGICAL MANAGEMENT
The main drug of choice for cardiac tamponade
is DOPAMINE as it….
• Stimulates adrenergic receptors to increase
myocardial contractility and peripheral
resistance
• Supports blood pressure and cardiac output in
emergencies until bleeding is brought under
control; only used if fluid resuscitation is
initiated
• Infusion of dopamine, or norepinephrine
doubled cardiac output.

17. NURSING MANAGEMENT
Inpatient care.
• Oxygen Support
• Volume expansion with blood, plasma, or
isotonic sodium chloride solution, as necessary,
to maintain adequate intravascular volume &
note significant increase in cardiac output after
volume expansion
• Bed rest with leg elevation - This may help
increase venous return

18. CONTINUED
• After pericardiocentesis, leave the
intrapericardial catheter in place after securing
it to the skin using sterile procedure and
attaching it to a closed drainage system via a 3-
way stopcock. Periodically check for
reaccumulation.
• The catheter can be left in place for 1-2 days
and can be used. Serial fluid cell counts can be
useful for helps to find catheter infection, If the
(WBC) count rises, the pericardial catheter
must be removed immediately.

19. Emergency care
A Swan-Ganz catheter can be left in place for
continuous monitoring of hemodynamics and
to assess the effect of reaccumulation of
pericardial fluid. A repeat echocardiogram and
a repeat chest radiograph should be performed
within 24 hours.
• The highest nursing priority is to maintain the
patient’s ABCs.
• Emergency equipment should be readily
available, should the patient require intubation
and mechanical ventilation.

20. CONTINUED
• A number of nursing strategies increase the rate
of fluid replacement. Fluid resuscitation is most
efficient through a short, large-bore peripheral
intravenous(IV) catheter in a large peripheral
vein.
• Emotional support of the patient and family is
also a key nursing intervention.
• Answer the patient’s and family’s questions
about the risks of cardiac tamponade

21. NURSING DIAGNOSIS
• Impaired skin integrity related to irritation and
erosion; fluid volume deficit related to water
loss
OUTCOMES
• Wound healing
• Tissue integrity

22. CONTINUED…
• Decreased cardiac output related to reduced
ventricular filling secondary to increased
intrapericardial pressure.
OUTCOMES
• Capillary refill <3 sec
• HR 60 to 100 beats/min
• BP 90 to 120 mm Hg
• Pulse pressure 30 to 40 mm Hg
• Urine output 30 ml/hr or 1 ml/kg/hr