Cardiac tamponade
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| ICD-10 | I31.9 |
| ICD-9 | 423.9 |
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For a more extensive discussion of pericarditis and diseases of the pericardium, click here.
Overview
Cardiac tamponade, also known as pericardial tamponade, is a medical emergency condition in which fluid accumulates in the pericardium (the sac in which the heart is enclosed). The elevated pericardial pressure puts significant pressure on the heart, causing a decrease in diastolic filling of the ventricles, and hence in stroke volume. The end result is ineffective pumping of blood, shock and potentially death.
Causes
Cardiac tamponade occurs when the pericardial space fills up with fluid faster than the pericardial sac can stretch. If the amount of fluid increases slowly (such as in hypothyroidism) the pericardial sac can expand to contain a liter or more of fluid prior to tamponade occurring. If the fluid occurs rapidly (as may occur after trauma or myocardial rupture) as little as 100 ml can cause tamponade.[1]
Causes of increased pericardial effusion include hypothyroidism, trauma (either penetrating trauma involving the pericardium or blunt chest trauma), pericarditis (inflammation of the pericardium), iatrogenic trauma (during an invasive procedure), and ventricular rupture.
Cardiac tamponade is caused by a large or uncontrolled Pericardial effusion, that is the buildup of fluid inside the pericardium [1]. This commonly occurs as a result of chest trauma (both blunt & penetrating) [1], but can also be caused by myocardial rupture, cancer, uraemia, pericarditis, or during cardiac surgery [1], and rarely occurs during aortic dissection [1] or whilst the patient is taking anticoagulant therapy [1].
The effusion can occur rapidly (as in the case of trauma or myocardial rupture), or over a more gradual period of time (as in cancer). The fluid involved is often blood, but pus is also found in some circumstances [1]
Myocardial rupture is a somewhat uncommon cause of pericardial tamponade. It typically happens in the subacute setting after a myocardial infarction (heart attack), in which the infarcted muscle of the heart thins out and tears. Myocardial rupture is more likely to happen in the elderly, females, patients with hypertension, and individuals without any previous cardiac history who suffer from their first heart attack and are not revascularized either with thrombolytic therapy or with percutaneous coronary intervention or with coronary artery bypass graft surgery.[1] These patients more often have single vessel disease without development of collaterals.
Pathophysiology
The outer pericardium is made of fibrous tissue [1] which does not easily stretch, and so once fluid begins to enter the pericardial space, pressure starts to increase [1].
If fluid continues to accumulate, then with each successive diastole, less and less blood enters the ventricles, as the increasing pressure presses on the heart and forces the septum to bend into the left ventricle, leading to decreased stroke volume [1]. This causes obstructive shock to develop, and if left untreated then Cardiac arrest may occur (in which case the presenting rhythm is likely to be Pulseless electrical activity)
Diagnosis
Physical Examination
Initial diagnosis can be challenging, as there are a number of differential diagnoses, including Tension pneumothorax [1], and acute heart failure.
Classical cardiac tamponade presents three signs, known as Beck's triad. Hypotension occurs because of decreased stroke volume, jugular venous distension due to impaired venous return to the heart, and muffled heart sounds due to fluid inside the pericardium [1] Another sign of tamponade on physical examination includes pulsus paradoxus (a drop of at least 10 mmHg in arterial blood pressure on inspiration) [1]. There may also be general signs & symptoms of shock (such as tachycardia, breathlessness and decreasing level of consciousness).
Electrocardiographic Findings
Tamponade may be associated with ST segment changes on the electrocardiogram [1]. Given the insulating properties of the fluid, there may also be low voltage QRS complexes [1]. In some cases, electrical alternans will be present in which case the height of the QRS varies from beat to beat. Tachycardia will likely be present as well.
 Cardiac Tamponade with Electrical Alternans |
 12 lead EKG shows Cardiac Tamponade with Electrical Alternans |
Chest X Ray
Tamponade can be diagnosed radiographically if the fluid has accumulated slowly over time and if the patient is stable enough to have had a chest x-ray obtained. The chest x-ray will show an enlarged globular heart. [1]
Echocardiography
Echocardiography demonstrates the collection of pericardial fluid. The best view to visualize a pericardial effusion is the subcostal view. Signs of more advanced tamponade include indentation of the atrium and ventricle, and in later stages collapse of these structures. The location of the fluid should be characterized so that the feasability and safety of pericardiocentesis can be assessed. For example, the location of the fluid should be characterized as either circumferential, posterior or anterior. The cm of fluid thickness should be characterized. The presence of loculations should be described. Usually pericardiocentesis can be performed if there is over 0.5 cm of anterior fluid.
- Cardiac tamponade
- Left ventricular free wall rupture
- Collapse of right ventricle in patient with cardiac tamponade
Treatment
Pre-hospital care
Initial treatment given will usually be supportive in nature, for example administration of oxygen, and monitoring. There is little care that can be provided pre-hospital other than general treatment for shock.
Some pre-hospital providers will have facilities to provide pericardiocentesis, but this is generally futile if the patient has already suffered a cardiac arrest before arrival of the healthcare professional to undertake the procedure [1], and so rapid evacuation to a hospital is usually the more appropriate course of action.
Hospital management
Initial management in hospital is by pericardiocentesis [1]. This involves the insertion of a needle through the skin and into the pericardium, and aspirating fluid. Often, a cannula is left in place during resuscitation following initial drainage so that the procedure can be performed again if the need arises. If facilities are available, an emergency pericardial window may be performed instead [1], during which the pericardium is cut open to allow fluid to drain. Following stabilization of the patient, surgery is provided to seal the source of the bleed and mend the pericardium.
Pericardial window
Autopsy Studies of Cardiac Tamponade
 HEART: Myocardial Rupture Following Mitral Valve Replacement: Gross, an excellent example with valve and obviously ruptured heart wall. |
 HEART: Myocardial Rupture Following Mitral Valve Replacement: Gross, natural color view from within left ventricle caged plastic ball with steel complete struts |
 HEART: Myocardial Rupture Following Mitral Valve Replacement: Gross, natural color portion of caged plastic ball prosthesis shown with close-up of ruptured left ventricular wall |
 HEART: Myocardial Rupture Following Mitral Valve Replacement: Gross, natural color close-up view of torn myocardium and bottom of hetero or homograft valve |
 HEART: Infarct; Acute, Ruptured: Gross, natural color horizontal section ventricle anterior infarct not easily appreciated with thinning of myocardium |
 HEART: Rupture after myocardial infarction. |