Cardiac Tamponade


Article Author:
Eric Stashko


Article Editor:
Jehangir Meer


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
11/15/2018 10:14:50 PM

Introduction

Cardiac tamponade is a medical or traumatic emergency that happens when enough fluid accumulates in the pericardial sac compressing the heart and leading to a decrease in cardiac output and shock. The diagnosis of cardiac tamponade is a clinical diagnosis that requires prompt recognition and treatment to prevent cardiovascular collapse and cardiac arrest. The treatment of cardiac tamponade can be performed at the bedside or in the operating room.[1][2][3]

Etiology

Cardiac tamponade is caused by the buildup of pericardial fluid (exudate, transudate, or blood) that can accumulate for several reasons. Hemorrhage, such as from a penetrating wound to the heart or ventricular wall rupture after an MI, can lead to a rapid increase in pericardial volume. Other risk factors, which tend to produce a slower growing effusion, include infection (tuberculosis [TB], myocarditis), autoimmune diseases, neoplasms, uremia, and other inflammatory diseases (pericarditis). The pericardial fluid that builds up slowly is better tolerated in patients than rapid accumulations. Hence, traumatic causes (hemopericardium) require small volumes to causes hemodynamic instability versus pericardial effusions from medical causes such as malignancy where large volumes of fluid may accumulate in pericardial sac before patients become symptomatic.[4][5]

Epidemiology

The incidence or prevalence of pericardial effusions in the overall population is unknown. However, there are sub-groups of patients with a higher incidence of pericardial effusions. These include HIV-positive patients, patients with end-stage renal disease, those with known or occult malignancies, a history of congestive heart failure, tuberculosis, autoimmune diseases like lupus, or penetrating traumatic injury to central chest "cardiac box."[6][7]

Pathophysiology

Normally, a small, physiologic amount of fluid surrounds the heart within the pericardium. When the volume of fluid builds up fast enough, the chambers of the heart are compressed, and tamponade physiology develops rapidly with much smaller volumes. The classical example is the traumatic cardiac injury resulting in hemp-pericardium. Under this pressure, the chambers of the heart are unable to relax leading to decreased venous return, filling and cardiac output.

Slow growing effusions, such as those due to autoimmune disease or neoplasms, allow for stretching of the pericardium, and effusions can become quite large before leading to tamponade physiology.[8]

History and Physical

Patients with cardiac tamponade present similar to patients with other forms of cardiogenic or obstructive shock. They may endorse vague symptoms of chest pain, palpitations, shortness of breath, or in more severe cases, dizziness, syncope and altered mental status.  They may also present in a pulseless electrical activity cardiac arrest. The classic physical findings in cardiac tamponade included in Beck’s triad are hypotension, jugular venous distension, and muffled heart sounds. Pulses paradoxus, which is a decrease in systolic blood pressure by more than 10 mm Hg with inspiration is an important physical exam finding that suggests a pericardial effusion is causing cardiac tamponade. When fluid compresses the heart and impairs filling, the interventricular septum bows toward the left ventricle during inspiration due to increased venous return to the right side of the heart. This further decreases the of the left ventricle leading to decreased left ventricular preload and stroke volume.  The challenge with making the diagnosis of tamponade with clinical signs alone is difficult since they are neither sensitive nor specific.

Evaluation

The diagnosis of cardiac tamponade can be suspected on history and physical exam findings. ECG may be helpful, especially if it shows low voltages or electrical alternans, which is the classic ECG finding in cardiac tamponade due to the swinging of the heart within the pericardium that is filled with fluid. This is a rare ECG finding, and most commonly the ECG finding of cardiac tamponade is sinus tachycardia. A chest x-ray may show an enlarged heart and may strongly suggest pericardial effusion if a prior chest radiograph with a normal cardiac silhouette is available for comparison. CT chest can also pick up pericardial effusion.  [1][9]

Echocardiography is the best imaging modality to use at the bedside, whether it is a point-of-care echo or a cardiology echo study. Echocardiography can not only confirm there is a pericardial effusion, but determine its size, and whether it is causing compromise of cardiac function (right ventricular diastolic collapse, right atrial systolic collapse, plethoric IVC). The medical literature is replete with studies that show clinicians (non-cardiologists) with limited training using point-of-care echo can perform focused echocardiograms to answer specific questions such as whether there is a significant pericardial effusion.

Treatment / Management

The treatment of cardiac tamponade is the removal of pericardial fluid to help relieve the pressure surrounding the heart. This can be done by performing a needle pericardiocentesis at the bedside, performed either using traditional landmark technique in a sub-xiphoid window or using a point-of-care echo to guide needle placement in real-time.  Often the removal of the first small amounts of fluid can make a large improvement in hemodynamics, but leaving a catheter within the pericardium can allow for further drainage.[10][11][12]

Surgical options include creating a pericardial window or removing the pericardium. Emergency department resuscitative thoracotomy and the opening of the pericardial sac is therapy that can be used in traumatic arrests with suspected or confirmed cardiac tamponade. These options are preferable to needle pericardiocentesis for traumatic pericardial effusions.

Volume resuscitation and pressor support may be helpful; however, these are temporizing measures that should be performed while preparing for definitive treatment with one of the above procedures.

Differential Diagnosis

  • Pleural effusion
  • Pneumothorax
  • Pulmonary embolism
  • Constrictive pericarditis
  • Heart failure
  • Shock

Consultations

Cardiologist

Cardiac surgeon

 

Pearls and Other Issues

Diagnosis of pericardial effusion with tamponade can be difficult using clinical exam alone. A point-of-care echocardiogram can be very useful to confirm the diagnosis and determine the need for intervention. Remember, tamponade is ultimately a clinical diagnosis requiring both hemodynamically unstable patient and pericardial effusion.

Patients suspected of having cardiac tamponade due to medical causes should be monitored closely and acted on promptly as they can deteriorate quickly. These patients are by definition unstable and should be watched in the hospital following treatment. Further testing may better explain the etiology of the effusion. Pericardiocentesis, while effective, is not without risk. Complications include damage the nearby vessels (including puncturing a coronary vessel, internal mammary vessels), inadvertent puncture to the right ventricle or laceration of the liver. These complications may be reduced by using point-of-care ultrasound for guidance during pericardiocentesis, but this has not been well studied.

Penetrating traumatic pericardial tamponade require prompt surgical intervention: pericardial window if the patient has vital signs, or emergency department thoracotomy if the patient has no pulse. Hemopericardium in blunt traumatic arrest is considered a non-survivable injury, and further resuscitation is not usually warranted.

Enhancing Healthcare Team Outcomes

Cardiac tamponade is a surgical emergency and patients may present to the emergency department or on the cardiac surgery floor. The nurse must be aware of this disorder as time is of the essence. The condition can rapidly lead to hypotension, shock, and death. Once the condition is diagnosed, the patient is best monitored in the ICU until the fluid is evacuated from the pericardial sac. Oxygen is usually required, and the patient is placed at bed rest with the feet elevated. After treatment, the patient needs to be monitored to ensure that the fluid does not re-accumulate. If a drain is left in the pericardial sac, the nurse should monitor the drainage. A follow-up echo is usually done prior to discharge.[13][14] (Level V)

Outcomes

Once cardiac tamponade is diagnosed, treatment is required. Without treatment, the condition is universally fatal. Data show that cardiac tamponade following open heart surgery is often fatal. In all cases, the underlying cause must be treated. When the cause of the pericardial effusion is a malignancy, it carries an 80% mortality within 12 months, whereas patients with a non-malignant cause have a mortality rate of less than 15%.[2][15](Level V)


Attributed To: Contributed by Emory EM US section

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Cardiac Tamponade - Questions

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Which condition must be excluded before one can make a definitive diagnosis of tamponade?



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In a patient with acute cardiac tamponade, which of the following should not be done?



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Which of the following is not a feature of Beck triad?



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A 17-year-old female is shot medially to the right scapula. Vitals initially were blood pressure 90/P, pulse 120 bpm and respirations 32. Paramedics administered 2 liters of normal saline via 2 lines and high flow oxygen by mask. In the emergency department, the patient is diaphoretic and agitated. Heart sounds cannot be heard secondary to environmental noise. Neck veins are flat. Her respiratory status and blood pressure worsen over several minutes, but she is still oriented x 3 and conscious. What is the next step in management?



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Which is a clinical sign of cardiac tamponade?



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During an emergency department thoracotomy, tamponade is suspected and the pericardium is opened. What is the safest technique for opening the pericardium?

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Attributed To: Contributed by Wikimedia Commons (CC BY 2.0) https://creativecommons.org/licenses/by/2.0/deed.en



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Which of the following is a non-surgical cause of acute cardiac tamponade?



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Which option is not part of the Beck triad is seen with cardiac tamponade.



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What is the pathology behind cardiac tamponade?



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A 65-year-old female is brought to the emergency department after a motor vehicle accident. She was hit head-on while traveling on a highway. She is in severe pain and holding her chest. There is a large contusion on the anterior chest, muffled heart sounds, pulsus paradoxus, and jugular venous distension. Her blood pressure is 85/55 mm Hg. What is the initial step in management?



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A patient is involved in a motor vehicle accident at 100 mph. The patient was a restrained driver and is clutching his chest secondary to chest pain. There are muffled heart sounds, jugular venous distension, pulsus paradoxus, and the impression of the steering wheel on his chest. Blood pressure is 85/55. What should be done?



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A 60 year old female presents with dizziness and shortness of breath. She is receiving chemotherapy for breast cancer. She is afebrile, pulse is 135 and blood pressure is 90/65. A bedside echocardiogram is quickly performed showing a moderate pericardial effusion. Which of the following additional findings would suggest her symptoms are due to cardiac tamponade?



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A 55-year-old male recently diagnosed with pericarditis presents for new shortness of breath, palpitations, and near syncope while walking into the clinic. His heart rate is 160 beats/min with sinus rhythm and blood pressure is 80/60 mmHg. On exam, he has distended neck veins, distant heart sounds, and the patient is clearly in distress. A bedside ultrasound shows a large pericardial effusion (see video below). What is the best treatment?

Attributed To: Contributed by Emory EM US section



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Which of the following causes pulsus paradoxus with a drop in systolic blood pressure by more than 10 mmHg with inspiration that occurs in cardiac tamponade?



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A 34-year-old male patient presents to the emergency department with moderate retrosternal chest pain for 3 days. The pain is worse on deep inspiration and relieved by lying down. There was no associated cough, wheezing, sputum production, or orthopnea. He has no known medical history, does not smoke, and takes no medication regularly. The patients lifts weights regularly, and believed it was from "working out too much". The pain somewhat responded to over the counter ibuprofen and acetaminophen, but 2 hours ago, he developed sudden shortness of breath which brought him to the hospital. Blood pressure is 95/65 mmHg, heart rate is 110/bpm, temperature is 36.7 C, respiratory rate is 22/minute and spO2 is 95 percent on room air. He appears to be in moderate distress. Auscultation of the lungs reveals good air entry bilaterally, without crackles. Heart sounds are muffled. There is noticeable jugular venous distention when sitting upright on the examination table. What is the most appropriate next step in management?



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A postoperative patient following a mitral valve has been complaining of shortness of breath. An echocardiogram reveals left ventricular diastolic collapse. What is the next step?



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Of the following, which clinical feature is not associated with early tamponade?



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What is the most urgent scenario of cardiac tamponade that should prompt emergent pericardiocentesis?



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A 54-year-old male presents to the emergency department with acute onset shortness of breath and dizziness. Muffled heart sounds are heard on auscultation and distension of veins in the patient’s neck are noted. In a brief period of time, the patient’s blood pressure drops to 88/48 mmHg. What is the cause of the patient’s decreased cardiac function?



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A patient was admitted to the intensive care unit with a diagnosis of thrombotic thrombocytopenic purpura. He presented with a 12-hour history of altered mental status, abdominal pain, nausea, fever, and chills. Before admission, he ate a burger at a restaurant and became ill a few hours afterward. His blood pressure on admission was 85/65 mmHg, pulse 135 beats/min, respiratory rate 10, and temperature 102F. Blood work revealed a WBC of 12, CBC 9, hemoglobin 8.5, hematocrit 29%, platelets 5,000 platelets/microliter, prothrombin time 11, partial thromboplastin time 43, INR 1.4, BUN 33, creatinine 2.6, sodium 133, potassium 5.9, chloride 99, and glucose 90. Immediate plasmapheresis was recommended, and a central line was inserted in the right internal jugular vein using ultrasound guidance. Three minutes after line placement, the patient expired. His chest x-ray is shown below. What is the most likely cause of death?

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A patient has been admitted to the intensive care unit with a diagnosis of cardiac tamponade. What classic symptoms are in Beck's triad and might be indicative of acute cardiac tamponade? Select all that apply.



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What is Beck's triad?



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A 68-year-old male with a history of hypertension presented to the emergency room with acute shortness of breath, hypotension, and positional chest pain. Examination significant for blood pressure 80/40 mmHg, heart rate 100/minute, afebrile, muffled heart sounds, and elevated, non-collapsable jugular venous distension. There are no significant electrocardiogram changes. What should be done next?



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What is the most common non-traumatic cause of cardiac tamponade?



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A 65-year-old female with a history of hypertension, diabetes mellitus, presented with non-specific chest pain. During her hospital stay, she developed hypotension, change in mental status and examination showed muffled heart sounds, elevated jugular venous distension. She was diagnosed with cardiac tamponade. What is the next step in management?



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Cardiac Tamponade - References

References

Yacoub M,Bhimji SS, Pericarditis, Constrictive-Effusive null. 2018 Jan     [PubMed]
Schusler R,Meyerson SL, Pericardial Disease Associated with Malignancy. Current cardiology reports. 2018 Aug 20     [PubMed]
Rahim Khan HA,Gilani JA,Pervez MB,Hashmi S,Hasan S, Penetrating cardiac trauma: A retrospective case series from Karachi. JPMA. The Journal of the Pakistan Medical Association. 2018 Aug     [PubMed]
Aoyagi S,Kosuga T,Wada K,Nata SI,Yasunaga H, Pericardial injury from chest compression: a case report of incidental release of cardiac tamponade. Journal of intensive care. 2018     [PubMed]
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Imazio M, [Ten questions about cardiac tamponade]. Giornale italiano di cardiologia (2006). 2018 Sep     [PubMed]
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Adegbala O,Olagoke O,Adejumo A,Akintoye E,Oluwole A,Alebna P,Williams K,Lieberman R,Afonso L, Incidence and outcomes of cardiac tamponade in patients undergoing cardiac resynchronization therapy. International journal of cardiology. 2018 Jul 20     [PubMed]
Ancion A,Robinet S,Lancellotti P, [Cardiac tamponade]. Revue medicale de Liege. 2018 May     [PubMed]
Maldow DJ,Chaturvedi A,Kaproth-Joslin K, Every second counts: signs of a failing heart on thoracic CT in the ED. Emergency radiology. 2017 Jun     [PubMed]
The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery. The Annals of thoracic surgery. 2017 Mar     [PubMed]
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