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Cardiac tamponade

cardiac tamponade, cardiac tamponade symptoms
Cardiac tamponade, also known as pericardial tamponade, is when fluid in the pericardium the sac around the heart builds up and results in compression of the heart2 Onset may be rapid or more gradual2 Symptoms typically include those of cardiogenic shock including shortness of breath, weakness, lightheadedness, and cough Other symptoms may relate to the underlying cause1

Common causes include cancer, kidney failure, chest trauma, and pericarditis2 Other causes include connective tissue diseases, hypothyroidism, aortic rupture, and following cardiac surgery4 In Africa, tuberculosis is a relatively common cause1

Diagnosis may be suspected based on low blood pressure, jugular venous distension, pericardial rub, or quiet heart sounds21 The diagnosis may be further supported by specific electrocardiogram ECG changes, chest X-ray, or an ultrasound of the heart2 If fluid increases slowly the pericardial sac can expand to contain more than 2 liters; however, if the increase is rapid as little as 200 mL can result in tamponade2

When tamponade results in symptoms, drainage is necessary5 This can be done by pericardiocentesis, surgery to create a pericardial window, or a pericardiectomy2 Drainage may also be necessary to rule out infection or cancer5 Other treatments may include the use of dobutamine or in those with low blood volume, intravenous fluids1 Those with few symptoms and no worrisome features can often be closely followed2 The frequency of tamponade is unclear6 One estimate from the United States places it at 2 per 10,000 per year3

Contents

  • 1 Signs and symptoms
  • 2 Causes
    • 21 Surgery
  • 3 Pathophysiology
  • 4 Diagnosis
  • 5 Treatment
    • 51 Pre-hospital care
    • 52 Hospital management
  • 6 Epidemiology
  • 7 References
  • 8 External links

Signs and symptomsedit

Onset may be rapid or more gradual2 Symptoms typically include those of cardiogenic shock including shortness of breath, weakness, lightheadedness, and cough1 Other symptoms may relate to the underlying cause1

Causesedit

Cardiac tamponade is caused by a large or uncontrolled pericardial effusion, ie the buildup of fluid inside the pericardium7 This commonly occurs as a result of chest trauma both blunt and penetrating,8 but can also be caused by myocardial rupture, cancer, uremia, pericarditis, or cardiac surgery,7 and rarely occurs during retrograde aortic dissection,9 or while the person is taking anticoagulant therapy10 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 circumstances7

Causes of increased pericardial effusion include hypothyroidism, physical trauma either penetrating trauma involving the pericardium or blunt chest trauma, pericarditis inflammation of the pericardium, iatrogenic trauma during an invasive procedure, and myocardial rupture

Surgeryedit

One of the most common settings for cardiac tamponade is in the first 24 to 48 hours after heart surgery After heart surgery, chest tubes are placed to drain blood These chest tubes, however, are prone to clot formation When a chest tube becomes occluded or clogged, the blood that should be drained can accumulate around the heart, leading to tamponade

Pathophysiologyedit

Hemopericardium, wherein the pericardium becomes filled with blood, is one cause of cardiac tamponade

The outer layer of the heart is made of fibrous tissue11 which does not easily stretch, so once fluid begins to enter the pericardial space, pressure starts to increase7

If fluid continues to accumulate, each successive diastolic period leads to less blood entering the ventricles Eventually, increasing pressure on the heart forces the septum to bend in towards the left ventricle, leading to a decrease in stroke volume7 This causes the development of obstructive shock, which if left untreated may lead to cardiac arrest often presenting as pulseless electrical activity

Diagnosisedit

Play media An ultrasound of the heart showing cardiac tamponade12

Initial diagnosis can be challenging, as there are a number of differential diagnoses, including tension pneumothorax,8 and acute heart failurecitation needed In a trauma patient presenting with PEA pulseless electrical activity in the absence of hypovolemia and tension pneumothorax, the most likely diagnosis is cardiac tamponade13

Signs of classical cardiac tamponade include three signs, known as Beck's triad Low blood pressure occurs because of decreased stroke volume, jugular-venous distension due to impaired venous return to the heart, and muffled heart sounds due to fluid buildup inside the pericardium14

Other signs of tamponade include pulsus paradoxus a drop of at least 10 mmHg in arterial blood pressure with inspiration,7 and ST segment changes on the electrocardiogram,14 which may also show low voltage QRS complexes,10 as well as general signs and symptoms of shock such as fast heart rate, shortness of breath and decreasing level of consciousness However, some of these signs may not be present in certain cases A fast heart rate, although expected, may be absent in people with uremia and hypothyroidism1

In addition to the diagnostic complications afforded by the wide-ranging differential diagnosis for chest pain, diagnosis can be additionally complicated by the fact that patients will often be weak or faint at presentation For instance, a fast rate of breathing and difficulty breathing on exertion that progresses to air hunger at rest can be a key diagnostic symptom, but it may not be possible to obtain such information from patients who are unconscious or who have convulsions at presentation1

Tamponade can often be diagnosed radiographically Echocardiography, which is the diagnostic test of choice, often demonstrates an enlarged pericardium or collapsed ventricles A large cardiac tamponade will show as an enlarged globular-shaped heart on chest x-ray During inspiration, the negative pressure in the thoracic cavity will cause increased pressure into the right ventricle This increased pressure in the right ventricle will cause the interventricular septum to bulge towards the left ventricle, leading to decreased filling of the left ventricle At the same time, right ventricle volume is markedly diminished and sometimes it can collapse10

Play media
Apical ultrasound image of the heart in a person with cardiac tamponade Note how the right atrial collapses during systole12 
Play media
Ultrasound image of the inferior vena cava IVC in a person with cardiac tamponade Note that the IVC is large and changes minimally with breathing12 

Treatmentedit

Pre-hospital careedit

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 teams have performed an emergency thoracotomy to release clotting in the pericardium caused by a penetrating chest injury

Prompt diagnosis and treatment is the key to survival with tamponade Some pre-hospital providers will have facilities to provide pericardiocentesis, which can be life-saving If the patient has already suffered a cardiac arrest, pericardiocentesis alone cannot ensure survival, and so rapid evacuation to a hospital is usually the more appropriate course of action

Hospital managementedit

Initial management in hospital is by pericardiocentesis8 This involves the insertion of a needle through the skin and into the pericardium and aspirating fluid under ultrasound guidance preferably This can be done laterally through the intercostal spaces, usually the fifth, or as a subxiphoid approach1516 A left parasternal approach begins 3 to 5 cm left of the sternum to avoid the left internal mammary artery, in the 5th intercostal space17 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,8 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

In people following heart surgery the nurses monitor the amount of chest tube drainage If the drainage volume drops off, and the blood pressure goes down, this can suggest tamponade due to chest tube clogging In that case, the patient is taken back to the operating room for an emergency reoperation

If aggressive treatment is offered immediately and no complications arise shock, AMI or arrhythmia, heart failure, aneurysm, carditis, embolism, or rupture, or they are dealt with quickly and fully contained, then adequate survival is still a distinct possibility

Epidemiologyedit

The frequency of tamponade is unclear6 One estimate from the United States places it at 2 per 10,000 per year3 It is estimated to occur in 2% of those with stab or gunshot wounds to the chest18

Referencesedit

  1. ^ a b c d e f g h i j Spodick, DH Aug 14, 2003 "Acute cardiac tamponade" The New England Journal of Medicine 349 7: 684–90 PMID 12917306 doi:101056/NEJMra022643 
  2. ^ a b c d e f g h i j k l m Richardson, L November 2014 "Cardiac tamponade" JAAPA : official journal of the American Academy of Physician Assistants 27 11: 50–1 PMID 25343435 doi:101097/01jaa0000455653425438a 
  3. ^ a b c Kahan, Scott 2008 In a Page: Medicine Lippincott Williams & Wilkins p 20 ISBN 9780781770354 
  4. ^ Schiavone, WA February 2013 "Cardiac tamponade: 12 pearls in diagnosis and management" Cleveland Clinic journal of medicine 80 2: 109–16 PMID 23376916 doi:103949/ccjm80a12052 
  5. ^ a b Sagristà-Sauleda, J; Mercé, AS; Soler-Soler, J 26 May 2011 "Diagnosis and management of pericardial effusion" World journal of cardiology 3 5: 135–43 PMC 3110902  PMID 21666814 doi:104330/wjcv3i5135 
  6. ^ a b Bodson, L; Bouferrache, K; Vieillard-Baron, A October 2011 "Cardiac tamponade" Current Opinion in Critical Care 17 5: 416–24 PMID 21716107 doi:101097/mcc0b013e3283491f27 
  7. ^ a b c d e f Porth, Carol; Carol Mattson Porth 2005 Pathophysiology: concepts of altered health states 7th ed Hagerstwon, MD: Lippincott Williams & Wilkins ISBN 0-7817-4988-3 
  8. ^ a b c d Gwinnutt CL, Driscoll PA 2003 Trauma Resuscitation: The Team Approach 2nd ed Oxford: BIOS ISBN 1-85996-009-X 
  9. ^ Isselbacher EM, Cigarroa JE, Eagle KA Nov 1994 "Cardiac tamponade complicating proximal retrograde aortic dissection Is pericardiocentesis harmful" Circulation 90 5: 2375–8 PMID 7955196 doi:101161/01CIR9052375 
  10. ^ a b c Longmore, J M; Murray Longmore; Wilkinson, Ian; Supraj R Rajagopalan 2004 Oxford handbook of clinical medicine 6th ed Oxford Oxfordshire: Oxford University Press ISBN 0-19-852558-3 
  11. ^ Patton KT, Thibodeau GA 2003 Anatomy & physiology 5th ed St Louis: Mosby ISBN 0-323-01628-6 
  12. ^ a b c Smith, Ben 27 February 2017 "UOTW #78 - Ultrasound of the Week" Ultrasound of the Week Retrieved 13 March 2017 
  13. ^ American College of Surgeons Committee on Trauma 2007 Advanced Trauma Life Support for Doctors, 7th Edition Chicago: American College of Surgeons
  14. ^ a b Holt L, Dolan B 2000 Accident and emergency: theory into practice London: Baillière Tindall ISBN 0-7020-2239-X 
  15. ^ Shlamovitz, Gil 4 August 2011 "Pericardiocentesis" Medscape Retrieved 16 August 2011 
  16. ^ Yarlagadda, Chakri 11 August 2011 "Cardiac Tamponade Treatment & Management" Medscape Retrieved 16 August 2011 
  17. ^ Synovitz CK, Brown EJ 2011 Chapter 37 Pericardiocentesis In Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T Eds, Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e Retrieved September 19, 2014 from http://accessmedicinemhmedicalcom/contentaspxbookid=348&Sectionid=40381499
  18. ^ Marx, John; Walls, Ron; Hockberger, Robert 2013 Rosen's Emergency Medicine - Concepts and Clinical Practice Elsevier Health Sciences p 448 ISBN 1455749877 

External linksedit

Classification
  • ICD-10: I319
  • ICD-9-CM: 4233
  • MeSH: D002305
External resources
  • MedlinePlus: 000194
  • eMedicine: med/283 emerg/412
  • Patient UK: Cardiac tamponade



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