an emergency medical condition

1. CARDIAC TAMPONADE
BY: RAJINA SHAKYA
MN 2ND YEAR

2. ANATOMY OF PERICARDIUM
• Fibro-elastic sac that envelope heart
• Two layers:
• Outer: parietal pericardium (consists of
fibrous and serous tissue )
• Inner : visceral pericardium (consists
only serous tissue) also known as
epicardium)
• Space between two layers: pericardial
space

3. CARDIAC TAMPONADE
Cardiac: heart , tamponade: pressure
Cardiac Emergency
Cardiac tamponade is a life threatening condition where
there is excess fluid accumulation in pericardial space
which exerts pressure in the heart muscles.
Or
Compression of all cardiac chambers due to excessive
accumulation of pericardial fluid leading to compromised
cardiac output.

4. EPIDEMIOLOGY
• Incidence : 2-5 cases per 10000
• 2% penetrating injuries result into cardiac tamponade
• In children more common in boys, boys: girls 7:3
• In adults male: female = 1.25:1
• Cardiac tamponade related to trauma or HIV is common
among young adults
• US, 2018

5. ETIOLOGY
• Cardiac tamponade develops due to pericardial effusion
• Pericardial effusion: accumulation of excess fluid in
pericardial space
• Pericardial effusion may occur rapidly or insidiously
• 19% of tuberculosis patients presented cardiac
tamponade. (Shakya & Jha 2018)

6. ETIOLOGY
Rapid pericardial effusion
• Trauma : both stabbing and
blunt
• Post myocardial infarction
• Heart surgery (open heart
surgery, CABG)
• Aortic dissection
• Drugs and medications (
antihypertensives)
Insidious pericardial effusion
• Cancers ( lung or breast cancer)
30-60%
• Infections (viral, bacterial, fungal)
5-10%
• Uremic pericarditis (10-15%)
• Hypothyroidism
• Chronic inflammation of
connective tissue (SLE, rheumatoid

7. PATHOPHYSIOLOGY
Pleural effusion due to various causes exert pressure in
heart walls
Impairs relaxation and filling of the ventricles
Chambers do not fill properly
Less cardiac output (too little oxygen reaches the tissues)
Hypotension increase heart rate ,faster breathing, feeling
of panic, swollen neck veins

8. CLINICAL FEATURES
• Pulsus paradoxus
Beck’s triad
• Distended jugular veins
• Hypotension
• Distant heart sounds
Others
• Tachycardia
• Coughing , chest pain
• Dyspnea(kussumaul’s
breathing)
• Weakness
• Decreased urine output
• Cyanosis of lips and nails
• Confusion, dysphoria

10. DIAGNOSIS
1. History an d physical examination
2. Chest x-ray: cardiomegaly, bottle shape heart, chest
wall trauma
3. ECG – tachycardia, low QRS complex voltage, electrical
alternans, ST segment changes
4. Echocardiography: excess fluid, swinging heart
5. Cardiac catheterization (Swan-Ganz): pressure in all
chambers are equal

12. LAB STUDIES
• Creatine kinase and isoenzymes: elevated in MI and
cardiac trauma
• Renal profile : uremia if uremic pericarditis
• Coagulation studies : helpful to determine bleeding risk
to interventions
• Antinuclear antibody assay and ESR: connective tissue
disorder

13. TREATMENT
• Immediate pericardiocentesis or pericardectomy and
monitored in ICU
• Supplemental oxygen
• Volume expansion with blood plasma, isotonic normal saline
to maintain adequate intravascular volume
• Bed rest with leg elevation (increase venous return)
• Intravenous Antibiotics
• Management of underlying conditions

14. GUIDELINES OF EUROPEAN SOCIETY OF
CARDIOLOGY, 2014
According to the guidelines, patients with suspected cardiac tamponade
should undergo echocardiography without delay.
After diagnosis, patients are scored according to disease etiology,
clinical presentation, and imaging findings.
A score of 6 or more requires the patient to undergo immediate
pericardial drainage.
A lower score indicates that drainage can be postponed for up to 12 to
48 hours.

15. PERICARDIOCENTESIS
• Also known as pericardial tap
• Is a surgical procedure( both diagnostic and therapeutic)
in which abnormal or excessive fluid is removed from the
pericardial sac.
• Removal of 5- 10 ml may dramatic increase stroke
volume and cardiac output by 25- 50%.

16. METHODS OF PERICARDIOCENTESIS
1. Emergency subxiphoid percutaneous drainage: blind
technique, life-saving bed side procedure, subxiphoid
approach is extra pleural, hence safest for performing
without echocardiographic guidance. 4% mortality and
17 % complications
2. Echocardiography guided pericardiocentesis: done in
cathlab, catheter is left for continuous drainage
3. Percutaneous balloon pericaridotomy: same as echo-
guided, balloon is used for creating window for

18. INDICATIONS OF PERICARDIOCENTESIS
• Pericarditis
• Trauma
• Surgery or other invasive procedures performed on the
heart cancer and MI
• Congestive heart failure
• Renal failure

19. PRECAUTIONS
• An echocardiogram should be performed to confirm the
presence of the pericardial effusion and to guide
pericardiocentesis needle during the procedure
• Since there is risk of accidental puncture to major
arteries or organs during procedure, surgical drainage
may be preferred treatment option for pericardial
effusion in non emergency situations

20. POST PERICARDIOCENTESIS CARE
• Secure pericardiocentesis catheter in place
• Periodically check for accumulation and drain
• Repeat
• Usually catheter is left in place for 1-2 days, within that
period monitor serum cell counts, increased WBC
indicates infection and requires immediate removal of
catheter

21. SURGICAL MANAGEMENT
• Surgical opening of a pericardial window: surgical opening
of communication between pericardial space and
intrapleural space
• Open thoracotomy and pericardiotomy may be required in
some cases
• If recurrent cardiac tamponade or pleural effusion
a. Sclerosing pericardium (instillation of stroids, tetracyclines
or antineoplastic drugs in pericardial space via
intrapericardial catheter

22. MEDICATIONS
• Role of medications is limited
• However by stimulating beta receptors , stroke volume
and cardiac output can be increased
• Dobutamine

23. COMPLICATIONS
• Cardiac arrest
• Myocardial infarction
• Arrhythmias
• Lacerations of heart muscles
• Puncture or rupture of coronary arteries
• Hemothorax, pneumothorax
• Pneumo pericardium
• Pulmonary edema , shock, death

24. NURSING MANAGEMENT
• Assessment :
• Assess the client status
• Monitor hemodynamic status (pulse, heart rate, blood
pressure, respiration rate)
• Assess neurologic status (LOC, orientation, confusion,
anxiety)
• Cardiovascular assessment (heart rate, jugular vein
distention, skin color)

25. NURSING DIAGNOSIS
• Decreased cardiac output related to reduced ventricular
filling secondary to increased intrapericardial pressure.
• Activity Intolerance Related To Impaired Cardiac
Performance

26. NURSING INTERVENTION
• Monitor ECG for dysrhythmia (may occur due to MI), BP every 5-
15 min during acute phase, pulsus paradoxus via arterial
tracing or during manual BP reading, urine output hourly.
(Reduced renal perfusion)
• Provide supplemental oxygen and IV fluids with two large bore
IV lines
• Provide pre and post op care ( assistance in investigations,
imparting knowledge regarding disease, treatment and
outcomes.
• Medications like dobutamine to increase myocardial contractility

27. REFERENCES
• Williams L. And Hopper P. Understanding medical
surgical nursing. 4th edition. 2012. Jaypee brothers
publications. India
• SANDRA M. NETTINA. LIPPINCOTT MANUAL OF NURSING
PRACTICE. 10TH EDITION(2014). WOLTERS KLUWERS
HEALTH. INDIA
• Brunner and Suddharth. Medical surgical nursing.
• https://www.Slideshare.Net/anilkumargowda/cardiac-
tamponade-79014744