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Cardiac Tamponade
Aka: Cardiac Tamponade, Pericardial Tamponade, Beck's Triad
- See Also
- Pericardial Effusion
- Pericarditis
- Echocardiogram
- Emergency Pericardiocentesis
- Oncologic Emergency
- Definitions
- Cardiac Tamponade
- Compression of heart by fluid in pericardial sac resulting in hemodynamic instability
- Pathophysiology
- Physiologic effects of effusion vary by timing
- Gradual accumulation is accomodated by sack stretch (up to 250 ml)
- Rapid accumulation results in 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
- Causes
- See Pericardial Effusion
- Symptoms
- Common
- Dyspnea
- Fatigue
- Other symptoms
- Orthopnea
- Chest Pain
- Syncope
- Signs
- Classic presentation (Beck's Triad)
- Hypotension
- Narrow Pulse Pressure
- Quiet 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
- Cardiopulmonary Shock
- Kussmaul's Sign
- Cold clammy skin
- Tachycardia
- Falling arterial pressure
- Narrow Pulse Pressure
- Hypotension
- Cyanosis
- Imaging: Chest XRay
- Enlarged cardiac shadow: Globular appearance
- Diagnostics
- Echocardiogram (preferred study)
- Focused Assessment with Sonography for Trauma (FAST)
- See Pericardial Effusion for Echocardiogram findings
- 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
- Diagnosis
- Pulsus Paradoxus with Pericardial Effusion confirms diagnosis
- Differential Diagnosis: Shock states
- Myocardial Infarction
- Septic Shock
- Pulmonary Embolism
- Management: Emergent
- Immediate Pericardiocentesis under Ultrasound guidance (ATLS)
- See Emergency Pericardiocentesis
- Sub-xiphoid approach
- Needle angled toward left Shoulder
- 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
- 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
- Management: Malignancy specific
- Consider reaccumulation prevention (post-stabilization)
- Chemotherapy
- Radiation
- Sclerosis