Cardiac Tamponade

David Ray Velez, MD

See Also:

Pathophysiology

Definition: Pericardial Fluid Accumulation Causes Increased Pressure and Impairs Cardiac Filling with Reduced Stroke Volume

Pathophysiology

Cardiac Filling Impeded by Pericardial Fluid Causing Compression of the Cardiac Chambers
Impairs Filling Once the Pericardial Pressure Exceeds the Diastolic (Filling) Pressure
First Sign of Tamponade: Decreased Right Atrium Filling (Lowest Pressure of the Four Chambers and the First to Collapse)
Speed of Accumulation:
- Rapid Accumulation of Even a Small Amount of Blood is Higher Risk for Collapse
- Even Larger Volumes Can Be Well Tolerated if They Accumulate Slowly Over Weeks-Years
May Serve a Protective Effect in Penetrating Cardiac Injury to Limit Extra-Pericardial Hemorrhage

Phases

Phase I: Increased Pericardial Pressure
- Output Maintained by Tachycardia, Increased SVR, and Filling Pressure
Phase II: Diminished Cardiac Output
Phase III: Intrapericardial Pressure Approaches Ventricular Filling Pressure
- Causes Cardiac Arrest from Profound Coronary Hypoperfusion

Causes

Symptoms

Physical Exam

The Majority of Patients are Tachycardic
Hypotension is Variable and is Often Not Present if Tachycardia is Able to Compensate for the Decreased Stroke Volume
Physical Exam Findings in General are Neither Highly Sensitive nor Specific
Pulsus Paradoxus: Decreased BP > 10 mmHg During Inspiration (Normal < 10 mmHg)
- Inspiration Increases Venous Return and Enlarged RV Impairs LV Filling
Beck’s Triad:
- Jugular Venous Distention (JVD)
- Muffled Heart Sounds
- Hypotension with Narrow Pulse Pressure
Kussmaul’s Sign: JVD Upon Inspiration

Diagnosis

Primary Testing:
- Ultrasound (Echocardiography, POCUS, FAST) – The Primary Tool for Diagnostic Evaluation
- Chest Xray
- EKG
Highly Suggestive if There are Clinical Signs/Symptoms of Tamponade with Ultrasound Showing Pericardial Effusion and Echocardiographic Signs of Tamponade
Diagnosis is Only Definitively Confirmed by Clinical Response to Pericardial Fluid Drainage

Subxiphoid Pericardial Window

Used in Trauma as a Diagnostic Tool, Not Therapeutic
Less Commonly Preformed Now; But Consider if FAST is Equivocal
Procedure:
- 10 cm Midline Incision Over Xiphoid
- Dissect toward the Cardiac Impulses to Find the Pericardium
- Grasp Pericardium Between Two Alice Clamps
- 1-2 cm Longitudinal Incision in the Pericardium
- Field Flooded with Fluid
Results:
- Positive: Bloody Fluid (Caution: Clotted Blood May Be Dry on Incision)
- Negative: Clear or Straw-Colored Fluid

Pericardial Effusion on POCUS ²

Traumatic Cardiac Tamponade

Median Sternotomy
- The Primary Treatment for Cardiac Tamponade in Trauma
- Avoid Intubation Until in the OR and Already Prepped – Can Rapidly Decompensate Upon Induction
Pericardiocentesis
- Generally Not Used in Trauma
- May Consider Pericardiocentesis to Temporize Prior to the OR if Acutely Unstable
- *See Pericardiocentesis
Resuscitative Thoracotomy
- May Require Resuscitative Thoracotomy for Sudden Decompensation or Cardiac Arrest Prior to the OR
- *See Resuscitative Thoracotomy

Non-Traumatic Cardiac Tamponade

Pericardiocentesis
- The Primary Treatment for Cardiac Tamponade Outside of Trauma
- *See Pericardiocentesis
Fluid Bolus May Be Able to Temporarily Support While Awaiting Definitive Management
Indications for Surgical Median Sternotomy:
- Concerned for Bleeding/Traumatic Injury
- Inaccessible to Pericardiocentesis
- Effusion Small or Loculated
- Need for Biopsy
- Coagulopathic

COVER: BruceBlaus. Wikimedia Commons. (License: CC BY-3.0)
Seif D, Perera P, Mailhot T, Riley D, Mandavia D. Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. Crit Care Res Pract. 2012;2012:503254. (License: CC BY-3.0)