Cardiac Tamponade

Cardiac Tamponade

Normal amt of pericardial fluid = 20-50 mL

Tamponade occurs when lg or rapidly formed
effusions incd pressure in the pericardial space
throughout the cardiac cycle
During inspiration, RV volume incs & in tamponade,
the RV is unable to expand into the maximally
stretched pericardium L-ward bulging of the
interventricular septum decd LVEDV decd
cardiac output & decd SBP during inspiration

Etiology of Cardiac Tamponade

HIV, bacterial (incl mycobacterial), viral, fungal

CA - Esp lung, breast, Hodgkins, mesothelioma

Radiation tx

Meds - Hydralazine, Procainamide, INH, Minoxidil

Post-MI (free wall ventricular rupture, Dresslers syndrome)

Connective tissue dzs SLE, RA, Dermatomyositis

Uremia

Trauma

Iatrogenic (eg, from TLC / PA Cath / TV pacemaker insertion, coronary

dissection & perforation, sternal bx, pericardiocentesis, GE jnx surgeries)
Other - Pneumopericardium (d/t mech ventilation or gastropericardial
fistula), Pleural effusions
Idiopathic

Clinical Presentation

Sxs

Chest Pain, dyspnea, near-syncope

Generally more comfortable sitting forward
Sxs c/w the underlying cause of tamponade

Physical Exam

Becks Triad - Elevd JVP, hypotension, decd heart sounds

JVP w/ preserved x descent and dampened or absent y descent

Generally w/ narrow pulse pressure

Tachycardia, other signs of HF (tachypnea, diaphoresis, cool

extremities, cyanosis, etc)
Pulsus paradoxus
Decd or absent cardiac impulse
+/- Friction rub

Pulsus Paradoxus

Dec in SBP > 10-12 mmHg

w/ inspiration
Can also occur in pts w/
COPD, pulm dz, PTX,
severe asthma

Can have tamponade

w/o pulsus paradoxus

In pts w/ pre-existing
elevs in diastolic
pressures and/or volume
(eg, LV dysfnx, AI and
ASD)

Diagnosis

Tamponade is a Clinical Diagnosis

Other Detection Methods

EKG

CXR

TTE

R Heart Cath

CT, MRI

EKG Findings

Common Findings

Sinus tachycardia
Non-specific ST segment and T wave changes
Changes assocd w/ acute pericarditis (incl diffuse STE & PR
depression)

Other Findings

Decd voltage (non-specific and can also be d/t emphysema,

infiltrative myocardial dz, PTX, etc)
Electrical alternans (specific but relatively insensitive for lg
effusions)

2/2 anterior-posterior swinging of the heart w/ each beat

Best seen in leads V2 to V4

Combined P wave and QRS complex alternation (specific for

cardiac tamponade)

EKG Findings

CXR Findings

Sudden inc in size of

cardiac silhouette w/o
specific chamber
enlargement
Effacement of the
normal cardiac borders
Development of a flask
or H2O-bottle shaped
heart

Lateral CXR Findings

May have (+) fat pad sign

Separation of mediastinal /
retrosternal fat and
epicardial fat by > 2 mm

TTE

Test of choice for rapid assessment of pericardial effusions, but these

findings are often absent in pts w/ pulm HTN or RVH
Characteristic Findings

Pericardial effusion

End-diastolic chamber collapse

RV expiratory collapse in early diastole (low sens, high spec)

RA expiratory collapse in late diastole (high spec if inward movement lasts > 30%
of cardiac cycle)
LA collapse (present in ~ 25%, highly spec)

Respiratory variation in transvalvular velocities during passive diastolic

filling.

Size often correlates w/ risk of tamponade but not always

Transmitral resp varn > 25% transtricuspid varn > 50% are char of tamponade.

IVC dilated & fails to collapse w/ inspiration (reflects elevd CVP)

Small cardiac chambers
Swinging of the heart anteroposteriorly w/in the pericardial effusion
Reciprocal size changes w/ respiration b/w RV & LV & their valves

TTE w/ Large Pericardial Effusion

R Heart Cath

Near equalization
(w/in 5 mm Hg) of
the RA, RV, PCWP,
RV diastolic, & LV
diastolic pressures
RA pressure
tracings show
diminshed systolic
y descent

Tx of Cardiac Tamponade

If mild, can sometimes tx w/ medical mgmt

Including 1 or more of the following: NSAIDs,

Colchcine, and/or steroids, depending on the
suspected cause.
Require very close monitoring, including w/ serial
TTEs and/or RHC

Tx of Cardiac Tamponade

Most require urgent/emergent pericardiocentesis

Closed pericardiocentesis

Open Pericardiocentesis in the OR

Generally in cath lab but can be at bedside

Subxiphoid approach under echo guidance is most common minimizes risk & can assess completeness of fluid removal
Can alternatively use Fluoroscopic guidance
Pigtail catheter often left in place

May be best for loculated effusions, effusions containing clots or

fibrinous material, and/or effusions that are borderline in size
Allow for bx and creation of a pericardial window for recurrent
effusions

Bedside pericardiocentesis if pt is in extremis

Emergency Bedside Pericardiocentesis

16- or 18-gauge
needle inserted at
angle of 30-45 to
the skin, near the
left xiphocostal
angle, aiming toward
the L shoulder

Tx of Cardiac Tamponade Other Measures

IVFs, especially if hypovolemic or if diuretics were

given for dx of HF
Temporary inotropic support (Dobutamine,
Dopamine)

Serial echos after draining the fluid

Analysis of pericardial fluid

Only has a low yield in determining the etiology of

pericardial dz
Can send for specific gravity, pH, glc, LDH, protein, cell
count, cytology, staining & Cx for bacteria, fungi, & TB).

Tx of Recurrent Effusions

Pericardectomy

Pericardial-peritoneal shunt

Pericardiodesis - Steroids, tetracycline, or

anti-neoplastic drugs administered into the
pericardial space sclerosis of the
pericardium

References

Spodick, DH. Acute cardiac tamponade. N Engl J Med 2003; 349:684.

Internet Journal of Anesthesiology 2001: Cardiac Tamponade Secondary
To Suppurative Pericarditis. A Case Report And Review Of The
Literature
Troughton, RW, Asher, CR, Klein, AL. Pericarditis. Lancet 2004; 363:717.
Reddy, PS, Curtiss, EI, O'Toole, JD, Shaver, JA. Cardiac tamponade:
hemodynamic observations in man. Circulation 1978; 58:265.
Roy, CL, et al. Does this patient with a pericardial effusion have cardiac
tamponade. NEJM 2007; 297(16):1810-1818
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