Cardiac tamponade: Clinical sciences

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Introduction0:00–1:04

Cardiac tamponade is a life-threatening condition characterized by excessive fluid accumulation in the pericardial sac. The excess fluid exerts pressure on the heart and decreases the filling of the cardiac chambers, eventually reducing cardiac output.
Patients with cardiac tamponade are typically hemodynamically unstable and may quickly develop cardiovascular collapse and cardiac arrest, so they require prompt recognition and treatment with emergent drainage of the pericardial fluid to restore cardiac output.
Cardiac tamponade can occur due to bleeding, which is also known as hemopericardium, which typically occurs as result of chest trauma, aortic dissection, left ventricular free wall rupture, or iatrogenic as a result of medical intervention.
Cardiac tamponade can also occur due to effusive-constrictive pericarditis, often as a result of infection, uremia, or malignancy.Now, if an individual presents with signs or symptoms of cardiac tamponade, you should first perform an ABCDE assessment.

Unstable patient1:04–3:07

These individuals are typically unstable, so immediately stabilize their airway, breathing and circulation. Next, obtain IV access, put your patient on continuous cardiac and vital sign monitoring, and provide supplemental oxygen if needed.Now, here’s a clinical pearl to keep in mind!
Cardiac tamponade is associated with decreased cardiac filling that can result in obstructive shock. So, be careful with the administration of IV fluids, since an excess of fluid could increase cardiac preload.
In the setting of cardiac tamponade, where the cardiac filling is already impaired, an increase in the preload can potentially precipitate cardiovascular collapse.
Similarly, mechanical ventilation can increase intrathoracic pressure, causing further impairment to venous return and cardiac output.
Therefore, it’s best to avoid or delay it whenever possible.Next, you should obtain a focused history and physical exam.
History usually includes chest pain and shortness of breath. The physical exam may show tachycardia.
A classic finding is Beck triad, which consists of hypotension, muffled heart sounds, and jugular venous distension or JVD.
You may also observe the Kussmaul sign, where JVD worsens during inspiration due to a rise in jugular venous pressure. Lastly, some patients may show pulsus paradoxus, which is a drop in systolic blood pressure of 10 mmHg or more during inspiration.
Keep in mind though that pulsus paradoxus might be absent in patients with atrial septal defect, aortic regurgitation, elevated diastolic pressures, or pulmonary hypertension.
If your patient presents with these signs and symptoms, you should suspect cardiac tamponade! Next, order a 12-lead ECG, chest X-ray, and bedside echocardiogram.

Cardiac tamponade3:07–4:20

The ECG usually shows sinus tachycardia, and you might also see a decreased QRS amplitude. In severe cases, you may notice electrical alternans, which is a beat-to-beat variation in QRS amplitude that occurs as the heart swings anteriorly and posteriorly within the enlarged pericardial space, varying the relative distance from the ECG leads on the anterior chest wall to the heart.
Chest X-ray typically demonstrates the water bottle sign, which is an enlargement of the cardiac silhouette in the shape of a water bottle.
Finally, echocardiogram reveals pericardial effusion, collapse of the right atrium during ventricular systole, collapse of the right ventricle during ventricular diastole, and a dilated inferior vena cava.
All of these findings help confirm the diagnosis of cardiac tamponade.Now that you’ve confirmed your diagnosis, proceed with an emergent percutaneous pericardiocentesis to relieve the pericardial pressure.

Percutaneous pericardiocentesis4:20–5:19

Ideally, for optimal results, percutaneous pericardiocentesis is performed under ultrasound guidance. If ultrasound isn’t readily available, pericardiocentesis can be performed using a blind approach.
However, keep in mind there’s a higher risk of complications, such as pneumothorax and myocardial perforation. The procedure involves inserting a needle through the chest wall into the pericardial space to drain the excess fluid.
Even just a few milliliters of fluid removal can improve cardiac function! After the pericardial fluid has been aspirated, a catheter can be left in place in order to allow further drainage and prevent reaccumulation of the effusion.
Also, be sure to collect a sample of pericardial fluid for visual assessment and lab analysis. Now that the pericardium has been decompressed, perform a visual assessment of the collected fluid for the presence of blood.
If the pericardial fluid is grossly bloody, you’re dealing with a hemopericardium! Your next step is to revisit the history and physical exam findings to determine the underlying cause.

Hemopericardium5:19–7:24

History might reveal previous trauma to the chest wall, such as blunt trauma from a motor vehicle accident. On physical exam, you could see an open chest wound, such as a stab wound, or a flail chest.
If this is the case, the hemopericardium was probably caused by the chest trauma, so you should consult the surgical team.On the other hand, if your patient presents with acute tearing chest pain, and on the physical exam you notice weak peripheral pulses, suspect aortic dissection and consult the surgical team.Now, let’s say your patient has a history of recent myocardial infarction, and the physical exam reveals a new holosystolic murmur.
In this case, suspect a left ventricular free wall rupture and, again, consult the surgical team.Finally, if your patient had a recent cardiac procedure, like pacemaker lead placement or coronary angioplasty, suspect iatrogenic hemopericardium and, again, consult the surgical team.Now, here’s a clinical pearl to keep in mind!
During coronary angioplasty, a balloon is inflated in the lumen of the coronary artery to displace an obstructive plaque, which can cause a coronary artery to rupture.
Likewise, since pacemaker leads are often placed directly into the ventricular myocardium, they pose a risk of myocardial perforation if the lead is placed too deep.
In either case, blood can enter the pericardial sac and cause cardiac tamponade.Alright, now, let's go back to the visual assessment and discuss situations when pericardial fluid is not grossly bloody.
In this case, diagnose effusive-constrictive pericarditis and send the fluid to the lab for cytology and culture.First, let’s say that your patient reports fever and chills; the pericardial fluid appears cloudy or purulent; and cytology reveals a high white blood cell count.

Effusive-constrictive pericarditis7:24–10:15

In this case, you should suspect an infection, and start empiric antibiotics against the most common bacterial agents, including Streptococcus pneumoniae and Staphylococcus aureus.Next, assess culture results.
If the pathogen is identified, diagnose bacterial pericarditis, so don’t forget to tailor antibiotics based on results and start your patient on anti-inflammatory medications, such as NSAIDs and colchicine.
However, more commonly, your results will come back negative, so you should suspect viral pericarditis, which can be primarily caused by coxsackieviruses, HIV, and influenza.
In this case, just start your patient on anti-inflammatory medications like NSAIDs and colchicine. Next, let’s say your patient has end-stage renal disease or ESRD, and has missed dialysis.
In this case, the physical exam might reveal a frosty or velvety appearance of their skin; and the pericardial fluid could show mononuclear cells on cytology.
These findings are highly suggestive of uremic pericarditis, which might require urgent hemodialysis to remove the excess urea from their blood.
Finally, your patient might report a history of a known malignancy, typically lung cancer; or unintentional weight loss.
If the cytology reveals malignant cells, you can diagnose malignancy. The next step is to perform a workup to identify the primary origin of the malignancy if not known.
Also, consider consulting the surgical team. One last clinical pearl!
Autoimmune conditions, such as systemic lupus erythematosus, rheumatoid arthritis, and Sjogren syndrome, can also cause effusive-constrictive pericarditis and lead to cardiac tamponade.
After stabilization, treatment focuses on controlling the underlying disease. Recurrent cases may require more targeted management and surgical consultation for pericardiectomy.
Alright, as a quick recap... Cardiac tamponade is a life-threatening condition characterized by excessive fluid accumulation within the pericardial space.
These patients are unstable and require emergent management, followed by focused history and physical, ECG, CXR, and echocardiogram.
Once you diagnose cardiac tamponade, perform an emergent percutaneous pericardiocentesis and assess the pericardial fluid.
If the fluid is grossly bloody, that’s hemopericardium, which requires surgical consultation. On the other hand, if the pericardial fluid is not grossly bloody, diagnose effusive-constrictive pericarditis and send fluid to the lab for cytology and culture.

Review10:15–11:26

If you suspect an infection, start empiric antibiotics until you get culture results that either help you tailor or taper off antibiotics.
Patients with ESRD that missed dialysis can develop uremic pericarditis, which may require urgent hemodialysis. Finally, if pericardial fluid analysis reveals malignant cells, you will want to look for the primary malignancy and consider surgical consultation.
diagnose effusive constrictive pericarditis and send fluid to the lab for cytology and culture If you suspect an infection start empiric antibiotics until you get culture results that can either help you tailor or taper off antibiotics Patients with ESD that missed dialysis can develop uremic pericarditis which may require urgent hemodialysis Finally if pericardial fluid analysis reveals malignant cells you will want to look for