cardiac tamponade.doc

8/11/2019 cardiac tamponade.doc

1/10

Background

Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardialspace, resulting in reduced ventricular filling and subsequent hemodynamic compromise. Thecondition is a medical emergency, the complications of which include pulmonary edema, shock, anddeath. (See Pathophysiology, tiology, and Prognosis.!

The overall mortality risk depends on the speed of diagnosis, the treatment provided, and theunderlying cause of the tamponade. "ntreated, the condition is rapidly and universally fatal (see theimage below!. (See Presentation, #orkup, Treatment, and $edication.!

This anteroposterior%view chest radiograph shows a massive, bottle%shaped heart andconspicuous absence of pulmonary vascular congestion. &eproduced with permission from Chest, ')* '+*-.

Pathophysiology

The pericardium, which is the membrane surrounding the heart, is composed of - layers. The thickerparietal pericardium is the outer fibrous layer/ the thinner visceral pericardium is the inner serouslayer. The pericardial space normally contains -+%+m0 of fluid.

&eddy et al describe 1 phases of hemodynamic changes in tamponade. 2'3

Phase 4 % The accumulation of pericardial fluid causes increased stiffness of the ventricle,requiring a higher filling pressure/ during this phase, the left and right ventricular filling pressures arehigher than the intrapericardial pressure

Phase 44 % #ith further fluid accumulation, the pericardial pressure increases above the

ventricular filling pressure, resulting in reduced cardiac output (see the Cardiac 5utputcalculator!

Phase 444 % 6 further decrease in cardiac output occurs, which is due to the equilibration of

pericardial and left ventricular (07! filling pressuresPericardial effusions, which cause cardiac tamponade, can be serous, serosanguineous,hemorrhagic, or chylous.

The underlying process for the development of tamponade is a marked reduction in diastolic filling,which results when transmural distending pressures become insufficient to overcome increasedintrapericardial pressures. Tachycardia is the initial cardiac response to these changes to maintain the

cardiac output.

Systemic venous return is also altered during tamponade. 8ecause the heart is compressedthroughout the cardiac cycle due to the increased intrapericardial pressure, systemic venous return isimpaired and right atrial and right ventricular collapse occurs. 8ecause the pulmonary vascular bed isa vast and compliant circuit, blood preferentially accumulates in the venous circulation, at the e9penseof 07 filling. This results in reduced cardiac output and venous return.

The amount of pericardial fluid needed to impair diastolic filling of the heart depends on the rate offluid accumulation and the compliance of the pericardium. &apid accumulation of as little as '+m0 offluid can result in a marked increase in pericardial pressure and can severely impede cardiac output,2-3 whereas '+++ m0 of fluid may accumulate over a longer period without any significant effect ondiastolic filling of the heart. This is due to adaptive stretching of the pericardium over time. 6 morecompliant pericardium can allow considerable fluid accumulation over a longer period withouthemodynamic insult.
http://reference.medscape.com/calculator/cardiac-outputhttp://emedicine.medscape.com/article/157325-overviewhttp://refimgshow%281%29/http://reference.medscape.com/calculator/cardiac-outputhttp://emedicine.medscape.com/article/157325-overview


2/10


3/10

Cardiac tamponade is a medical emergency. The prognosis depends on prompt recognition andmanagement of the condition and the underlying cause of the tamponade. "ntreated, cardiactamponade is rapidly and universally fatal.

4n addition to treatment for the tamponade, all patients should also receive treatment for theconditionDs underlying cause in order to prevent recurrence.

4n a study of patients with cardiac tamponade, Cornily et al reported a '%year mortality rate of A).;in patients whose tamponade was caused by malignant disease, compared with '1.1; in patientswith no malignant disease. The investigators also noted a median survival of '+ days in patients withmalignant disease.2A3

Proceed toClinical Presentation

History

Symptoms vary with the acuteness and underlying cause of the tamponade. Patients with acutetamponade may present with dyspnea, tachycardia, and tachypnea. Cold and clammy e9tremitiesfrom hypoperfusion are also observed in some patients.

6 comprehensive review of the patientBs history usually helps in identifying the probable etiology of a

pericardial effusion. The following may be noted* Patients with systemic or malignant disease present with weight loss, fatigue, or anore9ia Chest pain may be the presenting symptom in patients with pericarditis or myocardial

infarction $usculoskeletal pain or fever may be present in patients with an underlying connective tissue

disorder 6 history of renal failure can lead to a consideration of uremia as the cause of pericardial

effusion Careful review of a patientBs medications may indicate that drug%related lupus caused the

pericardial effusion &ecent cardiovascular surgery, coronary intervention, or trauma can lead to the rapid

accumulation of pericardial fluid and tamponade23 &ecent pacemaker lead implantation or central venous catheter insertion can lead to the rapid

accumulation of pericardial fluid and tamponade23 Consider =47%related pericardial effusion and tamponade if the patient has a history of

intravenous (47! drug abuse or opportunistic infections 4nquire about chest wall radiation % 4e, for lung, mediastinal, or esophageal cancer 4nquire about symptoms of night sweats, fever, and weight loss, which may be indicative of

tuberculosis

Physical Examination

4n a retrospective study of patients with cardiac tamponade, the most common symptoms noted by&oy et al were dyspnea, tachycardia, and elevated @ugular venous pressure. 23 vidence of chest wallin@ury may be present in trauma patients.

Tachycardia, tachypnea, and hepatomegaly are observed in more than +; of patients with cardiactamponade, and diminished heart sounds and a pericardial friction rub are present in appro9imatelyone third of patients. Some patients may present with di>>iness, drowsiness, or palpitations. Cold,clammy skin and a weak pulse due to hypotension are also observed in patients with tamponade.

Beck triad


4/10

To measure the pulsus parado9us, patients are often placed in a semirecumbent position/ respirationsshould be normal. The blood pressure cuff is inflated to at least -+mm =g above the systolic pressureand slowly deflated until the first Forotkoff sounds are heard only during e9piration.

6t this pressure reading, if the cuff is not further deflated and a pulsus parado9us is present, the firstForotkoff sound is not audible during inspiration. 6s the cuff is further deflated, the point at which the

first Forotkoff sound is audible during both inspiration and e9piration is recorded.

4f the difference between the first and second measurement is greater than '- mm =g, an abnormalpulsus parado9us is present.

The parado9 is that while listening to the heart sounds during inspiration, the pulse weakens or maynot be palpated with certain heartbeats, while S'is heard with all heartbeats.

6 pulsus parado9us can be observed in patients with other conditions, such asconstrictive pericarditis,asthma, severe obstructive pulmonary disease, restrictive cardiomyopathy, pulmonary embolism,rapid and labored breathing, and right ventricular infarction with shock.

6 pulsus parado9us may be absent in patients with markedly elevated 07 diastolic pressures, atrialseptal defect, pulmonary hypertension, aortic regurgitation, low%pressure tamponade, or right heart

tamponade.

Kussmaul sign

This was described by 6dolph Fussmaul as a parado9ical increase in venous distention and pressureduring inspiration. The Fussmaul sign is usually observed in patients with constrictive pericarditis, butit is occasionally is observed in patients with effusive%constrictive pericarditisand cardiac tamponade.

Ewart sign

6lso known as the Pins sign, this is observed in patients with large pericardial effusions. 4t isdescribed as an area of dullness, with bronchial breath sounds and bronchophony below the angle ofthe left scapula.

he y descentThe ydescent is abolished in the @ugular venous or right atrial waveform. This is due to an increase inintrapericardial pressure, preventing diastolic filling of the ventricles.

!ysphoria

8ehavioral traits such as restless body movements, unusual facial e9pressions, restlessness, and asense of impending death were reported by 4kematsu in about -); patients with cardiac tamponade.2'+3

"ow-pressure tamponade

4n severely hypovolemic patients, classical physical findings such as tachycardia, pulsus parado9us,and @ugular venous distention were infrequent. SagristG%Sauleda et al identified low%pressure

tamponade in -+; of patients with cardiac tamponade.2''3

They also reported low%pressure tamponadein '+; of large pericardial effusions.

Proceed to !i##erential !iagnoses

!iagnostic Considerationsarly diagnosis with a high inde9 of suspicion is necessary to minimi>e morbidity and mortality fromtamponade.

0arge pleural effusion

Cases of cardiac tamponade have been reported with large pleural effusions. The increasedintrapleural pressure resulting from large pleural effusions can be transmitted to the pericardial spaceand impair ventricular filling, thus producing the hemodynamic equivalent of cardiac tamponade.

Tension pneumopericardium
http://emedicine.medscape.com/article/157096-overviewhttp://emedicine.medscape.com/article/157096-overviewhttp://emedicine.medscape.com/article/157216-overviewhttp://emedicine.medscape.com/article/157216-overviewhttp://emedicine.medscape.com/article/152083-differentialhttp://emedicine.medscape.com/article/157096-overviewhttp://emedicine.medscape.com/article/157216-overviewhttp://emedicine.medscape.com/article/152083-differential


5/10

The hemodynamic changes in tension pneumopericardium simulate acute cardiac tamponade.Clinically, distant heart sounds, bradycardia, and shifting tympany occur over the precordium, and acharacteristic murmur, termed bruit de la roue de moulin, is heard. This is usually observed in infantswith mechanical ventilation but is also seen after sternal bone marrow aspiration, penetrating chestwall in@ury, esophageal rupture, and bronchopericardial fistula.

&apid and labored breathing

0arge decreases in intrathoracic pressure with deep inspirations, often observed during respiratoryfailure, can accentuate pulsus parado9us, simulating pericardial tamponade.

!i##erential !iagnoses Cardiogenic Shock

Pericarditis, Constrictive

Pericarditis, Constrictive%ffusive

Pulmonary mbolism

Tension Pneumothora9

maging Studies

Chest radiography

Chest radiography findings may show cardiomegaly, a water bottleHshaped heart, pericardialcalcifications, or evidence of chest wall trauma. (See the image below.!

This anteroposterior%view chest radiograph shows a massive, bottle%shaped heart andconspicuous absence of pulmonary vascular congestion. &eproduced with permission from Chest, ')* '+*-.

6 bowed catheter sign on chest radiography in children after central venous catheter insertion may besuggestive of tamponade.2'-3

C scanning

Iold et al reported compression of the coronary sinus as observed through CT scanning as an earliermarker for cardiac tamponade in ?); of patients.2'13

Echocardiography

6lthough echocardiography provides useful information, cardiac tamponade is a clinical diagnosis.The following may be observed with -%dimensional (-%

6n echo%free space posterior and anterior to the left ventricle and behind the left atrium % 6fter

cardiac surgery, a locali>ed, posterior fluid collection without significant anterior effusion may occurand may readily compromise cardiac output
http://emedicine.medscape.com/article/152191-overviewhttp://emedicine.medscape.com/article/157096-overviewhttp://emedicine.medscape.com/article/157216-overviewhttp://emedicine.medscape.com/article/300901-overviewhttp://emedicine.medscape.com/article/424547-overviewhttp://refimgshow%281%29/http://emedicine.medscape.com/article/152191-overviewhttp://emedicine.medscape.com/article/157096-overviewhttp://emedicine.medscape.com/article/157216-overviewhttp://emedicine.medscape.com/article/300901-overviewhttp://emedicine.medscape.com/article/424547-overview


6/10

arly diastolic collapse of the right ventricular free wall (see the images below!

arly diastolic collapse of right ventricular free wall (subcostal view!.

arly diastolic collapse of right ventricular free wall (parasternal short%a9isview at aortic valve!.

0ate diastolic compressioncollapse of the right atrium (see the image below!

0ate diastolic collapse of right atrium (subcostal view!.

Swinging of the heart in its sac

07 pseudohypertrophy

4nferior vena cava plethora with minimal or no collapse with inspiration (see the image below!


7/10

6 descending thoracic aorta

6 catheter in the right ventricle

6n enlarged left atrium

6n annular subvalvular 07 aneurysm

6 bronchogenic cyst

$pproach Considerations6s previously stated, prompt diagnosis is key to reducing the mortality risk for patients with cardiactamponade. 6lthough cardiac tamponade is a clinical diagnosis, further assessment of the patientDscondition and diagnosis of the underlying cause of the tamponade can be obtained through labstudies, imaging studies, and electrocardiography.

chocardiography, for e9ample, can be used to visuali>e ventricular and atrial compressionabnormalities as blood cycles through the heart, while lab studies can demonstrate signs ofmyocardial infarction, cardiac trauma, and infectious disease.

"a% Studies

The following studies aid in the assessment of patients with cardiac tamponade*

Creatine kinase and isoen>ymes % levels are elevated in patients with myocardial infarctionand cardiac trauma

&enal profile and complete blood count (C8C! with differential % These tests are useful in the

diagnosis of uremia and certain infectious diseases associated with pericarditis

Coagulation panel % The prothrombin time and activated partial thromboplastin time are useful

for determining bleeding risk during interventions, such as pericardial drainage andor the placementof pericardial windows

6ntinuclear antibody assay, erythrocyte sedimentation rate, and rheumatoid factor % 6lthough

nonspecific, results from these tests may give clues to a connective tissue disease predisposing tothe development of pericardial effusion.

=47 testing % 6ppro9imately -?; of all pericardial effusions are reported to be associated with

=47 infection

Purified protein derivative testing % This is used to diagnose tuberculosis, which is animportant and not uncommon cause of pericardial effusion and tamponade.

Electrocardiography

#ith a '-%lead electrocardiogram (see the image below!, the following findings suggest, but are notdiagnostic for, pericardial tamponade*

Sinus tachycardia

0ow%voltage J&S comple9es

lectrical alternans % 6lso observed during supraventricular and ventricular tachycardia

P& segment depression 6 '-%lead electrocardiogram showingsinus tachycardia with electrical alternans. &eproduced with permission from Chest, ')/ '+*-.

Electrical alternans

6lternation of J&S comple9es, usually in a -*' ratio, on electrocardiographic findings is calledelectrical alternans. 4t is caused by movement of the heart in the pericardial space. lectrical alternansis also observed in patients with myocardial ischemia, acute pulmonary embolism, andtachyarrhythmias.

Pulse Oximetry
http://refimgshow%282%29/


8/10

&espiratory variability in pulse%o9imetry waveform is noted in patients with pulsus parado9us. 4n asmall group of patients with tamponade, Stone et al noted increased respiratory variability in pulse%o9imetry waveform in all patients.2'?3 This finding should raise the suspicion for hemodynamiccompromise. 4n patients with atrial fibrillation, pulse%o9imetry may aid in detecting the presence ofpulsus parado9us.

Swan-&an' Catheteri'ation8efore or after insertion of the Swan%Ian> catheter, the system must be >eroed after positioning thetransducer at the midpoint of the left atrium. Then calibrate the monitoring system. Prior to insertion,test the balloon and flush all of the ports. Then insert the catheter into one of the ma@or veins.

6t a depth of -+ cm, inflate the balloon and slowly advance the catheter, while continuouslymonitoring the pressure from the distal lumen. 6lways deflate the balloon before withdrawing theSwan%Ian> catheter. The waveforms help to indicate the position of the catheter tip if fluoroscopy isnot readily accessible.

6t appro9imately the ?+%+ cm mark, the wedge pressure is usually recorded. Secure the catheterposition, and obtain a chest radiograph to confirm the position.

4n tamponade, near equali>ation (within mm =g! of the right atrial, right ventricular diastolic,pulmonary arterial diastolic, and pulmonary capillary wedge pressure (reflecting left atrial pressure!occurs. The right atrial pressure tracings display a prominent systolicxdescent and abolishedsystolic ydescent.

8oltwood et al described the diastolic equali>ation of pulmonary capillary and right atrial pressures aspredominantly inspiratory/ this is known as the inspiratory traction sign. 2'3 4t results from inspiratorytraction of the taut pericardium by the diaphragm.

Histologic (indings

5ccasionally, a pericardial biopsy is performed when the etiology of the pericardial effusion thatcaused the tamponade is unclear. This is especially useful in cases of tuberculous pericardialeffusions, because cultures of the pericardial fluid in these cases rarely yield a positive result for

mycobacteria. =owever, granulomas seen on pericardial biopsy specimens are often seen in patientswith tuberculous pericarditis.

4n general, cytopathologic findings from pericardial fluid and histologic findings from pericardial biopsyspecimens depend on the underlying pathology. Cytologic e9amination identifies the etiopathologiccause of tamponade in about A; of cases. 2')3

Proceed to reatment ) *anagement

$pproach Considerations

Cardiac tamponade is a medical emergency. Preferably, patients should be monitored in an intensivecare unit. 6ll patients should receive the following*

59ygen

7olume e9pansion with blood, plasma, de9tran, or isotonic sodium chloride solution, as

necessary, to maintain adequate intravascular volume % SagristG%Sauleda et al noted significantincrease in cardiac output after volume e9pansion 2'A3 (see the Cardiac 5utputcalculator!

8ed rest with leg elevation % This may help increase venous return

4notropic drugs (eg, dobutamine! % These can be useful because they increase cardiac output

without increasing systemic vascular resistancePositive%pressure mechanical ventilation should be avoided because it may decrease venous returnand aggravate signs and symptoms of tamponade.

+npatient care

6fter pericardiocentesis, leave the intrapericardial catheter in place after securing it to the skin usingsterile procedure and attaching it to a closed drainage system via a 1%way stopcock. Periodically

check for reaccumulation of fluid, and drain as needed.
http://emedicine.medscape.com/article/152083-treatmenthttp://reference.medscape.com/calculator/cardiac-outputhttp://reference.medscape.com/calculator/cardiac-outputhttp://emedicine.medscape.com/article/152083-treatmenthttp://reference.medscape.com/calculator/cardiac-output


9/10

The catheter can be left in place for '%- days and can be used for pericardiocentesis. Serial fluid cellcounts can be useful for helping to discover an impending bacterial catheter infection, which could becatastrophic. 4f the white blood cell (#8C! count rises significantly, the pericardial catheter must beremoved immediately.

6 Swan%Ian> catheter can be left in place for continuous monitoring of hemodynamics and to assess

the effect of reaccumulation of pericardial fluid. 6 repeat echocardiogram and a repeat chestradiograph should be performed within -? hours.

Consultations

Consultations associated with cardiac tamponade can include the following*

=emodynamically stable patients % Cardiologist

=emodynamically unstable patients % Cardiologist, cardiothoracic surgeon

$cti,ity

4nitially, the patient should be on bed rest with leg elevation to increase the venous return. 5nce thesigns and symptoms of tamponade resolve, activity can be increased as tolerated.

(ollow-up6 follow%up echocardiogram and chest radiograph should be performed at a monthly follow%upe9amination to check for recurrent fluid accumulation.

Pericardiocentesis and Pericardiotomy

&emoval of pericardial fluid is the definitive therapy for tamponade and can be done using thefollowing 1 methods.

Emergency su%xiphoid percutaneous drainage

This is a life%saving bedside procedure. The sub9iphoid approach is e9trapleural/ hence, it is thesafest for blind pericardiocentesis. 6 ')% or '%gauge needle is inserted at an angle of 1+%?K to theskin, near the left 9iphocostal angle, aiming towards the left shoulder. #hen performed emergently,

this procedure is associated with a reported mortality rate of appro9imately ?; and a complicationrate of 'A;.

Echocardiographically guided pericardiocentesis

This is often carried out in the cardiac catheteri>ation laboratory. The procedure is usually performedfrom the left intercostal space. :irst, mark the site of entry based on the area of ma9imal fluidaccumulation closest to the transducer. Then, measure the distance from the skin to the pericardialspace. The angle of the transducer should be the tra@ectory of the needle during the procedure. 6voidthe inferior rib margin while advancing the needle to prevent neurovascular in@ury. 0eave a ')%gaugecatheter in place for continuous drainage.

Percutaneous %alloon pericardiotomy

This can be performed using an approach similar to that for echo%guided pericardiocentesis, with theballoon being used to create a pericardial window.

Surgical Care in Hemodynamically Unsta%le Patients

:or a hemodynamically unstable patient or one with recurrent tamponade, provide care as describedbelow.

Surgical creation o# a pericardial window

This involves the surgical opening of a communication between the pericardial space and theintrapleural space. This is usually a sub9iphoidian approach, with resection of the 9iphoid. =owever, aleft para9iphoidian approach with preservation of the 9iphoid has been described. 2'3

5pen thoracotomy andor pericardiotomy23

may be required in some cases, and these should beperformed by an e9perienced surgeon.


10/10

ecurrent cardiac tamponade or pericardial e##usion

Sclerosing the pericardium

This is a therapeutic option for patients with recurrent pericardial effusion or tamponade. Through theintrapericardial catheter, corticosteroids, tetracycline, or antineoplastic drugs (eg, anthracyclines,bleomycin! can be instilled into the pericardial space.

Pericardio-peritoneal shunt

4n some patients with malignant recurrent pericardial effusions, the creation of a pericardio%peritonealshunt helps to prevent recurrent tamponade.

Pericardiectomy

&esection of the pericardium (pericardiectomy! through a median sternotomy or left thoracotomy israrely required to prevent recurrent pericardial effusion and tamponade.

.ideo-$ssisted horascopic Procedure

4n a study of ' patients with cardiac tamponade, $onaco et al found that a modified, video%assisted

thoracoscopic procedure seemed to be a feasible treatment for the condition.2'3

"sing a right hemithoracic approach, the investigators employed a 'mm trocar on the fourth rightintercostal space on the anterior a9illary and a '+mm trocar on the seventh right intercostal space onthe median a9illary line.

"tili>ation of a mm optic allowed - instruments, for the optic and for the endoscopic forceps, to beemployed simultaneously using ' trocar/ this left the second trocar available for dissecting scissors.6ll patients underwent a pericardial resection equal to that achievable via an anterolateralthoracotomy.

The pericardial effusion was effectively drained in all patients, with no intraoperative mortality orperioperative morbidity encountered.

Proceed to *edication

*edication Summary

The role of medication therapy in cardiac tamponade is limited. 5ccasionally, inotropic agents that donot increase peripheral vascular resistance, such as the synthetic catecholamine dobutamine, may beused to increase cardiac output.

Cardio,ascular/ Other

Class Summary

8y stimulating beta%' receptors in the heart, these agents increase stroke volume and cardiac output.

7iew full drug information

!o%utamine

cardiac tamponade.doc

Documents