II. Definitions
- Cardiac Tamponade
- Compression of heart by fluid in pericardial sac resulting in hemodynamic instability
III. Pathophysiology
- Physiologic effects of effusion vary by timing
- Gradual accumulation is accomodated by sack stretch (up to 250 ml)
- Rapid accumulation results in more abrupt hemodynamic compromise
- Cardiac Tamponade pathway
- Effusion prevents diastolic relaxation of ventricles
- Right Ventricular Filling Pressure approaches left ventricular pressure
- Loss of normal pressure differentials prevents diastolic filling of heart
IV. Causes
V. Symptoms
- Common
- Other symptoms
VI. Signs
- Classic presentation (Beck's Triad)
- Hypotension
- Narrow Pulse Pressure
- Quiet or muffled heart sounds
- Cardiac exam
- Distended neck veins (Jugular Venous Distention)
- Increased Central Venous Pressure (CVP)
- Hyperdynamic JVP waveform (exaggerated X descent)
- Pulsus Paradoxus (pathognomonic for Pericardial Effusion)
- Faint heart sounds
- Friction rub
- Distended neck veins (Jugular Venous Distention)
- Cardiopulmonary Shock
- Kussmaul's Sign
- Cold clammy skin
- Tachycardia
- Falling arterial pressure
- Cyanosis
VII. Imaging: Chest XRay
- Enlarged cardiac shadow: Globular appearance
VIII. Diagnostics
-
Echocardiogram (preferred study)
- Focused Assessment with Sonography for Trauma (FAST)
- See Pericardial Effusion
- Right heart wall movement appears as a paradoxical rocking motion
- Right atrium collapse in systole (also occurs with Hypovolemic Shock)
- Right ventricular collapse of free wall in diastole (despite tricuspid valve opening, and RV filling)
- Inferior Vena Cava
- Does not collapse during inspiration when Cardiac Tamponade is present
-
Electrocardiogram
- Low voltage complexes
- Electrical alternans may be present
- Untreated, Pulseless Electrical Activity (PEA) may result
- Cardiac catheterization: Right-Left pressures equal
- Right ventricular diastolic pressure
- Pulmonary capillary wedge pressure
IX. Diagnosis
-
Bedside Ultrasound (see Echocardiogram above)
- Consider Bedside Ultrasound in all patients with Tachypnea, Shortness of Breath or Tachycardia
- Beck's Triad has low sensitivity (not all Cardiac Tamponade patients have Hypotension)
- Pulsus Paradoxus with Pericardial Effusion confirms diagnosis
X. Differential Diagnosis: Shock states
XI. Management: Emergent
- Immediate Pericardiocentesis under Ultrasound guidance (ATLS)
- See Emergency Pericardiocentesis
- Hypoperfusion with Cardiac Tamponade is an indication for Pericardiocentesis
- Sub-xiphoid approach with needle angled toward left Shoulder
- Parasternal approach has been advocated due to clear path to Pericardium
- Constant suction applied to syringe on entry
- Send fluid for cytology if not Traumatic in origin
-
Emergency Thoracotomy
- Indicated in Cardiac Tamponade due to Trauma (esp penetrating), refractory to Pericardiocentesis
- Emergent Cardiothoracic surgery
- Pericardial window placement and other definitive management
-
Intravenous Fluids
- Transient stabilization to increase venous pressure
- Norepinephrine may also be used to transiently improve perfusion
- Precautions
- Avoid Positive Pressure Ventilation until after decompression with Pericardiocentesis
- Negative intrathoracic pressure is the last safeguard maintaining venous return in Pericardial Tamponade
- Positive Pressure Ventilation eliminates negative intrathoracic pressure
- Pulseless Electrical Activity arrest (PEA arrest) results
- Avoid measures that reduce cardiac filling
- Avoid inotropes (increased Heart Rate decreases filling time)
- References
- Mallemat and Swadron in Herbert (2013) EM:Rap 13(12): 10-11
- Avoid Positive Pressure Ventilation until after decompression with Pericardiocentesis
XII. Management: Malignancy specific
- Consider reaccumulation prevention (post-stabilization)
- Chemotherapy
- Radiation
- Sclerosis
Images: Related links to external sites (from Bing)
Related Studies
| Definition (MSHCZE) | Komprese srdce nahromaděným výpotkem (PERIKARDIÁLNÍ EFÚZE) nebo krví (hemoperikard) v osrdečníku (PERIKARD). Srdeční výdej takto postiženého orgánu může dosahovat podob od minimálního až po celkový hemodynamický kolaps. (SRDCE – MINUTOVÝ OBJEM). |
| Definition (NCI_CDISC) | Compression of the heart caused by increased intrapericardial pressure due to the collection of blood or fluid in the pericardial space. Cardiac tamponade should usually be documented by either: Echocardiogram showing pericardial fluid and signs of tamponade such as right heart compromise, or systemic hypotension due to pericardial fluid compromising cardiac function. |
| Definition (NCI_FDA) | Acute compression of the heart caused by increased intrapericardial pressure due to the collection of blood or fluid in the pericardium from rupture of the heart, penetrating trauma, or progressive effusion. |
| Definition (NCI) | Acute compression of the heart caused by increased intrapericardial pressure due to the collection of blood or fluid in the pericardium from rupture of the heart, penetrating trauma, or progressive effusion. |
| Definition (NCI_CTCAE) | A disorder characterized by an increase in intrapericardial pressure due to the collection of blood or fluid in the pericardium. |
| Definition (CSP) | compression of heart from pericardial effusion or hemopericardium. |
| Definition (MSH) | Compression of the heart by accumulated fluid (PERICARDIAL EFFUSION) or blood (HEMOPERICARDIUM) in the PERICARDIUM surrounding the heart. The affected cardiac functions and CARDIAC OUTPUT can range from minimal to total hemodynamic collapse. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D002305 |
| ICD9 | 423.3 |
| ICD10 | I31.4 |
| SnomedCT | 266295005, 155341007, 194975004, 35304003 |
| English | Cardiac Tamponade, Cardiac Tamponades, Tamponade, Cardiac, Tamponades, Cardiac, heart tamponade, Tamponade, Pericardial, Pericardial Tamponade, Tamponades, Pericardial, Pericardial Tamponades, Rose's tamponade, cardiac tamponade, cardiac tamponade (diagnosis), Tamponade cardiac, Cardiac Tamponade [Disease/Finding], pericardial tamponade, tamponade cardiac, Tamponade, cardiac, CARDIAC TAMPONADE, Pericardial tamponade, Cardiac tamponade, Cardiac tamponade (disorder), tamponade; cardiac |
| Portuguese | TAMPONAMENTO CARDIACO, Tamponamento pericárdico, Tamponamento Pericárdico, Compressão Pericárdica, Compressão Cardíaca, Tamponamento cardíaco, Tamponamento Cardíaco |
| German | HERZTAMPONADE, Perikardtamponade, Herzbeuteltamponade, Herztamponade |
| Dutch | pericardtamponade, tamponade; hart, harttamponade, Harttamponade, Tamponade, hart- |
| Spanish | Taponamiento pericárdico, Taponamiento Pericárdico, Compresión Cardíaca, Compresión Pericárdica, taponamiento cardíaco (trastorno), taponamiento cardíaco, taponamiento pericárdico, Taponamiento cardiaco, Taponamiento Cardíaco |
| Swedish | Hjärttamponad |
| Japanese | ｼﾝﾏｸﾀﾝﾎﾟﾅｰﾃﾞ, ｼﾝﾀﾝﾎﾟﾅｰﾃﾞ, 心臓タンポナーデ, 心タンポナーデ, 心膜タンポナーデ |
| Finnish | Sydämen tamponaatio |
| French | Tamponnade péricardique, Tamponnade, TAMPONNADE, Tamponnade cardiaque |
| Russian | SERDTSA TAMPONADA, СЕРДЦА ТАМПОНАДА |
| Czech | Perikardiální tamponáda, Srdeční tamponáda, Tamponáda srdeční, srdce - tamponáda, srdeční tamponáda |
| Italian | Tamponamento pericardico, Tamponamento cardiaco |
| Polish | Tamponada serca |
| Hungarian | Szív tamponad, Pericardialis tamponad, Szívtamponad |
| Norwegian | Hjertetamponade |
