Basic approach to Cardiac temponade

1. Dr. Nauman Zafar PGR Medicine

2. Introduction
Etiology
Clinical Presentation
Investigations
Treatment

3.  Normal Amount of pericardial fluid = 20-50
mL
 The accumulation of fluid in the pericardial
space in a quantity sufficient to cause serious
obstruction to the inflow of blood to the
ventricles results in cardiac tamponade
 Tamponade occurs when long standing or
rapidly formed effusions  increased
pressure in the pericardial space throughout
the cardiac cycle

4.  Presence of impairment of hemodynamics
by the presence of the fluid in the pericardial
space differentiates it from simple effusion
 There are both limitation of ventricular filling
and reduction of cardiac output
 The quantity of fluid necessary to produce
this critical state may be 200 to >2000 mL
depending upon rapidity of fluid
accumulation

5.  Neoplasia : Carcinoma lung, Breast,
Hodgkin’s, Mesothelioma
 Idiopathic
 Renal Failure
 Infection :Viral (HIV), Bacterial
(Mycobacterium), Fungal
 Iatrogenic : Cardiac Surgery,
 Drugs : Anticoagulants, Hydralazine,
Procainamide, Isoniazid, Minoxidil

6.  Post myocardial Infarction :free wall
ventricular rupture, Dressler’s syndrome
 ConnectiveTissue Diseases : Systemic lupus
erythematosus, rheumatoid arthritis,
dermatomyositis
 Trauma

7.  Dyspnoea
 Chest Pain
 Palpitations
 Tachycardia
 Beck’sTriad : Hypotension, Jugular venous
distention, soft or absent heart sounds
 Pulsus Paradoxus : Fall in BP during
inspiration >10mmHg ( Normal <10mmHg)

9.  ECG :
 Low voltage
 Tachycardia,
 Electrical alternans ( due to heart swinging
backwards and forwards within a large fluid-
filled pericardium)

11. CXR:
 Water bottle heart
 Effacement of the normal cardiac borders
 Increase in size of cardiac silhouette

13.  Echocardiography:
 Pericardial
Tamponade With
Right-Sided Collapse
 Eff = effusion; LA =
left atrium; LV = left
ventricle; RA = right
atrium; RV = right
ventricle

18.  Right Heart Catheterization:
 Near equalization (w/in 5 mm Hg) of
the RA, RV, PCWP, RV diastolic, & LV
diastolic pressures

19.  Patients with acute pericarditis should be observed
frequently for the development of an effusion; if a
large effusion is present, the patient should be
hospitalized and pericardiocentesis carried out or
the patient should be watched closely for signs of
tamponade.
 Arterial and venous pressures and heart rate should
be monitored or followed carefully, and serial
echocardiograms obtained.

20.  If signs of hemodynamic compromise appear
 Pericardiocentesis – Echocardiographically or
fluoroscopically guided apical, parasternal, or,
most commonly, subxiphoid approach must be
carried out at once as reduction of the elevated
intrapericardial pressure may be lifesaving

21.  IV normal saline
administration
 A small, multiholed
catheter may be left in
place to allow draining
of the pericardial space
if fluid reaccumulates.

22. Surgical drainage :
 Through a limited (subxiphoid) thoracotomy
may be required in recurrent tamponade,
when it is necessary to remove loculated
effusions, and/or when it is necessary to
obtain tissue for diagnosis

23. Pericardial fluid analysis:
 Lactic (acid) dehydrogenase (LDH),
 Total protein Glucose fluid-to-serum ratio < 1
 TLC, DLC
 Gram stain
 Cultures
 Fluid hematocrit for bloody aspirates
 Cytology of pericardial fluid to for malignant
cells

24. Pericardial fluid:
 Exudative
 Neoplasm, tuberculosis, acute rheumatic
fever, post-cardiac injury, post MI
 Transudative
 Heart failure