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Updated: Apr 9 2022

Cardiac Tamponade

  • Snapshot
    • A 19-year-old man is stabbed in the left side of his chest. His blood pressure on presentation is 90/60 mmHg with a pulse of 130/min. On physical exam, he has muffled heart sounds and distended jugular veins. Upon inspiration, his blood pressure drops to 75/55 mmHg. His extremities are cool and clammy. He is immediately rushed to the operating room.
  • Introduction
    • Clinical definition
      • accumulation of fluid in the pericardial sac that restricts ventricular filling
    • Epidemiology
      • risk factors
        • pericarditis
        • malignancy
        • uremia
        • systemic lupus erythematosus
        • malignancy
        • tuberculosis
        • penetrating trauma
    • Etiology
      • pericardial effusion
      • hemorrhage into pericardial sac
      • iatrogenic
    • Pathoanatomy
      • pericardium
        • the pericardium is an elastic sac that can stretch to accommodate normal cardiac volume expansion
          • however, if stretched beyond normal physiological expansion, the pericardium will stiffen
    • Pathogenesis
      • cardiac tamponade
        • increased pericardial pressure from the fluid accumulation causes compression of the cardiac chambers
        • this results in decreased cardiac output and blood pressure
      • pulsus paradoxus
        • inhalation increases venous return → expands the right ventricle
          • in cardiac tamponade, the stiff pericardium will prevent the free wall from expanding
          • the only area for the right ventricle to expand is the interventricular septum, which will compress the left ventricle
          • compression of the left ventricle → decreased filling of the left heart → decreased blood pressure
    • Associated conditions
      • ruptured ascending aortic dissection
      • ventricular free wall rupture from myocardial infarction
    • Prognosis
      • in acute cases, cardiac tamponade can develop rapidly
      • in chronic cases, cardiac tamponade will develop gradually, as the pericardium can adjust slowly to the increased pressure over time
  • Presentation
    • Symptoms
      • chest pain
      • fatigability
      • often unresponsive to fluid resuscitation
    • Physical exam
      • Beck triad
        • muffled heart sounds
        • jugular venous distention
        • hypotension
      • cardiac
        • ↑ heart rate
        • pericardial rub if the patient has an inflammatory pericarditis
      • pulsus paradoxus
        • decrease of blood pressure > 10 mmHg during inhalation
      • pulmonary
        • shortness of breath
        • lung fields are typically clear
      • extremities
        • cold and clammy
        • peripheral cyanosis
  • Imaging
    • Echocardiography
      • indications
        • for diagnosis of cardiac tamponade
        • most accurate test
        • for all patients
      • findings
        • diastolic collapse of the right heart
        • fluid in the pericardial space
        • swinging of the heart within the effusion
    • Radiography
      • indication
        • for all patients
      • views
        • chest
      • findings
        • enlarged cardiac silhouette seen only in subacute cardiac tamponade
        • in acute cases, pericardium will not accomodate build up of > 200 cc of fluid, which is required to appear enlarged on radiograph
  • Studies
    • Electrocardiogram (ECG)
      • indication
        • for all patients
      • findings
        • low voltage
        • electrical alternans
          • variations in the height of the QRS complex
          • from swinging of the heart in the chest
    • Right heart catheterization
      • indication
        • typically not performed as an initial test
      • finding
        • equilibration of pressures in all 4 chambers during diastole
    • Making the diagnosis
      • based on clinical presentation, ECG, echocardiogram, and chest radiography
  • Differential
    • Constrictive pericarditis
      • distinguishing factors
        • also has pulsus paradoxus, but also presents with
          • Kussmaul sign
            • increase (or absence of decline) in jugular venous pressure with inhalation
          • pericardial knock
    • Tension pneumothorax
      • distinguishing factors
        • decreased or absent breath sounds
        • hyperresonant percussion
  • Treatment
    • Management approach
      • all approaches focus on removal of the fluid in the pericardium
    • Nonoperative
      • close monitoring and volume expansion
        • indication
          • cardiac tamponade without hemodynamic compromise
          • modalities
            • serial echocardiographs
            • intravenous bolus of fluids
    • Procedural
      • percutaneous pericardiocentesis
        • indication
          • first-line treatment
    • Operative
      • surgical drainage
        • indications
          • patients with coagulopathy or need for biopsy
          • purulent pericarditis
          • traumatic cardiac tamponade
      • surgical drainage with pericardial window placement
        • indication
          • patients with chronic pericardial effusions
          • patients who decompensate
  • Complications
    • Death
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