Updated: 4/1/2018

Cardiac Tamponade

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  • 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
  • Conservative
    • 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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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.CV.75) A 45-year-old male presents to the emergency department following a 5-car motor vehicle collision requiring mechanical extraction. On arrival to the ED, his airway is patent with normal breathing. His pulse is 110/min, blood pressure is 85/40 mmHg, respirations are 22/min, and oxygen saturation of 98% on room air. He is in clear distress and has the findings shown in Figure A. A chest radiograph and ultrasound examination are performed, which are shown in Figures B and C respectively. It is noted that his systolic BP decreases by 15 mmHg whenever he inspires. Which of the following diseases can exhibit a similar manifestation? Review Topic

QID: 106789
FIGURES:
1

Pleural effusion

10%

(11/106)

2

Rib fracture

6%

(6/106)

3

Tension pneumothorax

46%

(49/106)

4

Aortic dissection

12%

(13/106)

5

Congestive heart failure

24%

(25/106)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M1.CV.114) A 27-year-old male arrives in the emergency department with a stab wound over the precordial chest wall. The patient is in distress and is cold, sweaty, and pale. Initial physical examination is significant for muffled heart sounds, distended neck veins, and a 3 cm stab wound near the left sternal border. Breath sounds are present bilaterally without evidence of tracheal deviation. Which of the following additional findings would be expected on further evaluation? Review Topic

QID: 100630
1

Decrease in the patient's heart rate by 15 beats per minute with inspiration

0%

(0/11)

2

Elevated blood pressure to 170/110

0%

(0/11)

3

Steadily decreasing heart rate to 60 beats per minute

9%

(1/11)

4

15 mmHg decrease in systolic blood pressure with inspiration

82%

(9/11)

5

Decrease in central venous pressure by 5 mmHg with inspiration

0%

(0/11)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M1.CV.148) A 34-year-old patient is brought to the emergency room after a motor vehicle accident. An EKG shows sinus tachycardia and chest radiograph reveals an enlarged cardiac silhouette. While observing sinus tachycardia on the patient's telemetry, you note that the radial pulse cannot be palpated during inspiration. What should be the next step in management of this patient? Review Topic

QID: 100664
1

IV Heparin

0%

(0/5)

2

Pericardiocentesis

80%

(4/5)

3

Chest CT scan

0%

(0/5)

4

Pericardial window

0%

(0/5)

5

Insert chest tube

20%

(1/5)

M1

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PREFERRED RESPONSE 2
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