2. “Cardiac tamponade, also known as pericardial tamponade, is an
acute type of pericardial effusion in which fluid accumulates in the
pericardium leads to pressure on the heart muscle which
occurs when the pericardial space fills up with fluid faster than the
pericardial sac can stretch.”
Cardiac tamponade is a clinical syndrome caused by the
accumulation of fluid in the pericardial space, resulting in reduced
ventricular filling and subsequent hemodynamic compromise.
The condition is a medical emergency
INTRODUCTION
3. For all patients, malignant diseases are the most common cause of
pericardial tamponade
Malignant diseases - 30-60% of cases
Tamponade can occur as a result of any type of pericarditis.
Pericarditis can result from the following:
Human immunodeficiency virus (HIV) infection
Infection - Viral, bacterial (tuberculosis), fungal
ETIOLOGY
4. Other causes are:
Trauma to the chest(either penetrating trauma involving the
pericardium or blunt chest trauma)
Drugs - Hydralazine, procainamide, isoniazid, minoxidil
Postcoronary intervention - Ie, coronary dissection and perforation
Acupuncture
Postcardiac percutaneous procedures –
- Including mitral valvuloplasty
- atrial septal defect (ASD) closure
- left atrial appendage occlusion
5. Cardiovascular surgery - Postoperative pericarditis
Postmyocardial infarction - Free wall ventricular rupture, Dressler
syndrome
Connective tissue diseases - Systemic lupus erythematosus,
rheumatoid arthritis, dermatomyositis
Radiation therapy to the chest
Iatrogenic –
- After sternal biopsy
- transvenous pacemaker lead implantation
- pericardiocentesis
- central line insertion
- In first 24 to 48 hours after heart surgery. After heart surgery, chest
tubes are placed to drain blood. These chest tubes, however, are
prone to clot formation. When a chest tube becomes occluded or
clogged, the blood that should be drained can accumulate around
the heart, leading to tamponade.
6. Anticoagulation treatment
Idiopathic pericarditis
Complication of surgery at the esophagogastric junction - Eg,
antireflux surgery
Pneumopericardium - Due to mechanical ventilation or
gastropericardial fistula
Hypothyroidism
Still disease
Duchenne muscular dystrophy
Type A aortic dissection
7. The outer layer of the heart is made of fibrous tissue which
does not easily stretch, and so once fluid begins to enter
the pericardial space, pressure starts to increase.
If fluid continues to accumulate, then with each successive
diastolic period less and less blood enters the
ventricles the increasing pressure presses on the
heart and forces the septum to bend into the left ventricle
leading to decreased stroke volume
This causes obstructive shock to develop, and if left
untreated then cardiac arrest may occur
PATHOPHYSIOLOGY
8. Dyspnea,Tachycardia,Tachypnea
Dizziness, drowsiness, or palpitations
Cold, clammy extremities
H/0 Malignancy – weight loss, fatigue, anorexia
Chest pain – pericarditis, MI
MS pain – Fever , connective tissue disorder
Renal failure – uremia
Medications – drug related lupus
Recent cardiovascular surgery, coronary intervention, or
trauma
Recent procedure – pacemaker, central line
TB – night sweats, fever
Radiation – cancer history
SYMPTOMS
9. Beck triad
Described in 1935, this complex of physical findings,
also called the acute compression triad.
Refers to increased jugular venous pressure,
hypotension, and diminished heart sounds.
These findings result from a rapid accumulation of
pericardial fluid.
This classic triad is usually observed in patients with
acute cardiac tamponade.
PHYSICAL EXAMINATION
10. Tachycardia
Distant or muffled heart sounds
Hepatomegaly
Evidence of chest wall trauma
Pulsus paradoxsus > 12 mm Hg
Pulsus paradoxus (or paradoxical pulse) is an exaggeration (>12
mm Hg or 9%) of the normal inspiratory decrease in systemic
blood pressure.
Kussmaul sign - paradoxical increase in venous distention and
pressure during inspiration
Abolished y descent
11. Chest radiography
Chest radiography findings may show cardiomegaly, a water
bottle–shaped heart, pericardial calcifications, or evidence of
chest wall trauma.
DIAGNOSIS
12. CT scanning
Reveals compression of the coronary sinus an earlier marker for cardiac
tamponade in 46% of patients.
Echocardiogram (diagnostic test of choice)
Pericardial effusion
Early diastolic collapse of the right ventricular free wall
Late diastolic compression/collapse of the right atrium
Swinging of the heart in its sac
LV pseudohypertrophy
13.
14. ECG
ST segment changes on the ECG which may also show low voltage QRS
complexes
Sinus tachycardia, PR depression,
15. Pulse Oximetry
Respiratory variability in pulse-oximetry waveform is noted
in patients with pulsus paradoxus.
Lab Studies
16. Pre-hospital care
Initial treatment given will usually be supportive in nature.
Oxygen
Volume expansion with blood, plasma, or saline to
maintain adequate intravascular volume
Bed rest with leg elevation
- This may help increase venous return.
Inotropic drugs (i.e. dobutamine)
- Choose inotropes that do not increase systemic vascular
resistance while increasing cardiac output.
TREATMENT
17. Hospital management
• Initial management in hospital is by
pericardiocentesis.
• This involves the insertion of a needle
through the skin and into the pericardium and
aspirating fluid under ultrasound guidance
preferably.
• This can be done laterally through the
intercostal spaces, usually the fifth, or as a
subxiphoid approach.
• Often, a cannula is left in place during
resuscitation following initial drainage so that
the procedure can be performed again if the
need arises.
• If facilities are available, an emergency
pericardial window may be performed
instead, during which the pericardium is cut
open to allow fluid to drain.
• Following stabilization of the patient, surgery
is provided to seal the source of the bleed
and mend the pericardium.
