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Cardiac Tamponade

Cardiac tamponade is clinically defined as the accumulation of fluid such as blood in the pericardial sac which alters cardiac filling. Cardiac tamponade will usually present with hypotension, muffling of heart sounds, and accentuated neck veins. Because cardiac tamponade is a medical emergency, immediate attempts to evacuate the blood from the pericardium is of utmost priority to avoid mortality and further morbidity.


Presentation

The following symptomatology are observable in patients with cardiac tamponade:

  • Dyspnea – This results with the ineffective pulmonary delivery of the blood by the heart. 
  • Hypotension – Blood pressure drops with the progressive decrease in the systemic venous return.
  • Jugular enlargement – This vein engorges with the increasing jugular venous pressure [3]. 
  • Chest wall injuries – These findings are eminent in patients who had undergone chest trauma.
  • Tachypnea – This is a compensatory reaction of the lungs to oxygenate the blood in the advent of a decreasing cardiac output. 
  • Hepatomegaly – An acute or chronic passive congestion of the liver resulting to enlargement can occur due to the increasing venous pressure. 
  • Diminished or muffled heart sounds – This auscultatory finding is observable in cardiac tamponade patients due to the displacement of the heart secondary to the fluid accumulation. 
  • Paradoxical pulse (pulsus paradoxus) – The exaggerated pulse is generated due to the abrupt decrease in blood pressure during respiratory inspiration [4]. 
  • Kussmaul sign – This sign refer to the increased distention of jugular vein due to the increase in venous pressure during inspiration.
  • Dysphoria - This is a restless behavior exhibited by patients with cardiac tamponade as reaction to impending death [5].

Patients presenting with low blood pressure while in cardiac tamponade are unable to exhibit the Kussmaul sign, jugular venous distention, and pulsus paradoxus due to the hypovolemic state of the system. This type of cardiac tamponade is clinically referred to as low pressure tamponade occurring in 20% of all cardiac tamponade cases [6].

Congestive Heart Failure
  • Congestive heart failure (CHF) (5%) Collagen vascular disease (5%): systemic lupus erythematosus, rheumatoid arthritis Infection (4%) HIV Bacterial infection: Staphylococcus aureus, Mycobacterium tuberculosis, Streptococcus pneumoniae (rare) Fungal infection[unboundmedicine.com]
  • These include pericarditis, malignancy, trauma (penetrating, blunt, postsurgical, and iatrogenic), uremia, connective tissue diseases, myocardial infarction, congestive heart failure, and radiation.[web.archive.org]
Pallor
  • However, patient had bradycardia, and the other striking examination findings were coarse facies with pallor, madarosis, absent axillary and pubic hair and breast atrophy. Her blood sugar level was also low.[ncbi.nlm.nih.gov]
  • […] initially asymptomatic Shortness of breath, especially while lying down ( orthopnea ) Beck's triad Hypotension Muffled heart sounds Distended neck veins Tachycardia, pulsus paradoxus Retrosternal chest pain Apical impulse difficult to locate or nonpalpable Pallor[amboss.com]
Intravenous Drugs
  • The patient had several risk factors for aortic rupture and cardiac tamponade including intravenous drug use, pneumonia, and pregnancy.[ncbi.nlm.nih.gov]
  • This rare case of purulent pericarditis underscores the utility of bedside ultrasound in the ED and the complicated nature of altered mental status in intravenous drug users.[ncbi.nlm.nih.gov]
Dyspnea
  • Cardiac tamponade shares symptoms and signs such as dyspnea, edema, and low urine output with other, more-common diseases. Consider it when there is chest trauma or when the patient has a chronic medical illness that can involve the pericardium.[ncbi.nlm.nih.gov]
  • This leads to jugular venous distention, visceral organ engorgement, edema, and elevated pulmonary venous pressure that causes dyspnea.[doi.org]
  • These patients often develop frequent ascites and present with clinical signs and symptoms similar to cardiac tamponade (tachycardia, hypotension and dyspnea).[ncbi.nlm.nih.gov]
  • We report a case of eosinophilic granulomatosis with polyangiitis in a 50-year-old Caucasian woman who presented with chest pain, dyspnea at rest, fever, and periorbital swelling.[ncbi.nlm.nih.gov]
  • Typical symptoms of cardiac tamponade are jugular venous distension, pulsus paradoxus, hypotension, and rest dyspnea.[ncbi.nlm.nih.gov]
Tachypnea
  • The child had tachypnea and mild subcostal retractions. Investigations revealed open safety-pin in lower esophagus, and pericardial effusion that later progressed to cardiac tamponade during handling of the safety pin by endoscope.[ncbi.nlm.nih.gov]
  • Initial vital signs revealed mild tachycardia, mild tachypnea and blood pressure elevated to 162/84mm Hg along with a temperature of 38.7 C and oxygen saturation of 96% on 2l by nasal cannula.[ncbi.nlm.nih.gov]
  • Other signs of cardiac tamponade includes dyspnea, tachypnea, hepatomegaly, paradoxical pulses, and dysphoria.[symptoma.com]
  • Other frequent symptoms are pulsus paradoxus, pericardial friction sounds, tachycardia, tachypnea, weakened peripheral pulses, edema, cyanosis. Cardiac tamponade is seen in Video 1. Video 1. Cardiac tamponade.[ecgwaves.com]
  • Tachycardia, tachypnea, and hepatomegaly are observed in more than 50% of patients with cardiac tamponade, and diminished heart sounds and a pericardial friction rub are present in approximately one third of patients.[emedicine.medscape.com]
Dyspnea at Rest
  • We report a case of eosinophilic granulomatosis with polyangiitis in a 50-year-old Caucasian woman who presented with chest pain, dyspnea at rest, fever, and periorbital swelling.[ncbi.nlm.nih.gov]
Hypotension
  • Of the 7 hypotensive or normotensive patients diagnosed with cardiac tamponade, 4 underwent successful pericardiocentesis while awaiting surgery.[ncbi.nlm.nih.gov]
  • KEY POINTS Slow accumulation of pericardial fluid can result in edema, whereas rapid accumulation leads to hypotension.[doi.org]
  • After induction of general anesthesia for scrotal exploration and possible orchiopexy, the patient developed severe and persistent hypotension.[ncbi.nlm.nih.gov]
  • These patients often develop frequent ascites and present with clinical signs and symptoms similar to cardiac tamponade (tachycardia, hypotension and dyspnea).[ncbi.nlm.nih.gov]
Pulsus Paradoxus
  • Pulsus paradoxus Pulsus paradoxus (or paradoxical pulse) is an exaggeration ( 12 mm Hg or 9%) of the normal inspiratory decrease in systemic blood pressure.[emedicine.medscape.com]
  • Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers[scholar.harvard.edu]
  • Typical symptoms of cardiac tamponade are jugular venous distension, pulsus paradoxus, hypotension, and rest dyspnea.[ncbi.nlm.nih.gov]
  • This review explains the manifestations of tamponade, including a presentation in which the diagnostic finding of pulsus paradoxus is absent, and variant forms, such as low-pressure tamponade and regional tamponade.[doi.org]
  • While denying a history of any rash, photosensitivity, oral ulcers, or seizures, his physical examination did reveal metacarpal phalangeal joint swelling along with noted pulsus paradoxus of 15-200mmHg.[ncbi.nlm.nih.gov]
Tachycardia
  • Despite compensatory tachycardia, the decrease in cardiac filling leads to a fall in cardiac output and to arterial hypoperfusion of vital organs.[doi.org]
  • These patients often develop frequent ascites and present with clinical signs and symptoms similar to cardiac tamponade (tachycardia, hypotension and dyspnea).[ncbi.nlm.nih.gov]
  • On the same day, two episodes of sustained ventricular tachycardia and ventricular fibrillation without hemodynamic instability had to be promptly treated with antiarrhythmic drugs and electrical defibrillations.[ncbi.nlm.nih.gov]
  • Upon physical and cardiac examination, low blood pressure, low O2 saturation, tachycardia, and a muffled heart were observed.[ncbi.nlm.nih.gov]
  • Initial vital signs revealed mild tachycardia, mild tachypnea and blood pressure elevated to 162/84mm Hg along with a temperature of 38.7 C and oxygen saturation of 96% on 2l by nasal cannula.[ncbi.nlm.nih.gov]
Heart Disease
  • Author information 1 Department of Cardiology, 4(th) Military Hospital, Wroclaw, Poland; Department of Heart Disease, Faculty of Health Sciences, Medical University in Wroclaw, Wroclaw, Poland.[ncbi.nlm.nih.gov]
  • Braunwald's heart disease: a textbook of cardiovascular medicine. 7th ed. Philadelphia: WB Saunders; 2005:1757-1781. The diagnosis is based on clinical suspicion and supported by evidence of haemodynamic compromise on echocardiography.[bestpractice.bmj.com]
  • It can also occur due to heart disease and heart attack. Symptoms One symptom of cardiac tamponade is a sharp, stabbing chest pain that radiates to the neck, shoulder, back or abdomen.[nhcs.com.sg]
  • Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine . 11th ed. Philadelphia, PA: Elsevier; 2019:chap 83. Little WC, Oh JK. Pericardial diseases. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine . 25th ed.[nlm.nih.gov]
  • Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019:chap 83. Little WC, Oh JK. Pericardial diseases. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed.[nlm.nih.gov]
Distended Neck Veins
  • neck veins, worse with inspiration ( Kussmaul sign ) Diminished heart sounds ( Beck’s Triad : a combination of distended neck veins, hypotension, and diminished heart sounds) Cold, clammy extremities Anxiety, restlessness Diagnosis Blood tests EKG, Chest[cardiachealth.org]
  • […] tamponade : hypotension, muffled heart sounds, distended neck veins ![amboss.com]
  • Beck’s triad is a collection of three signs associated with cardiac tamponade: distended neck veins, muffled heart sounds, and hypotension. Pulsus paradoxus is also suggestive, consisting of a decrease in systolic BP of 10 mmHg during inspiration.[medcomic.com]
  • His cervical collar was removed, revealing distended neck veins (Figure). A bedside ultrasound demonstrated pericardial fluid (Video). Figure. Distended neck vein.[westjem.com]
  • Pericarditis Cancer Iatrogenic – can occur after cardiothoracic surgery Presentation Becks Triad – occurs in about 1/3 of patients with cardiac tamponade Hypotension Distended Neck Veins Muffled Heart Sounds Tachycardia Shortness of breath Chest pain[almostadoctor.co.uk]
Hepatomegaly
  • Other signs of cardiac tamponade includes dyspnea, tachypnea, hepatomegaly, paradoxical pulses, and dysphoria.[symptoma.com]
  • Evaluation: Perform a thorough H&P: VS abnormalities: persistent tachycardia (subacute/chronic) HEENT: JVD CV: muffled heart sounds, pericardial friction rub, peripheral edema Abdomen: hepatomegaly (subacute/chronic) Bedside echo 2,3 Subxiphoid and apical[emdocs.net]
  • Tachycardia, tachypnea, and hepatomegaly are observed in more than 50% of patients with cardiac tamponade, and diminished heart sounds and a pericardial friction rub are present in approximately one third of patients.[emedicine.medscape.com]
  • Cardiac Output: Results in hypotension and reactive tachycardia Left Heart Failure : Results in pulmonary edema and resultant dyspnea Right Heart Failure : Results in prominent increases in jugular venous pressure along with peripheral edema, ascites, and hepatomegaly[pathwaymedicine.org]
  • Signs Distended neck veins, hypotension, tachycardia, tachypnoea and hepatomegaly. Muffled heart sounds. Pericardial friction rub - present in 50% but may be transient.[patient.info]
Photosensitivity
  • While denying a history of any rash, photosensitivity, oral ulcers, or seizures, his physical examination did reveal metacarpal phalangeal joint swelling along with noted pulsus paradoxus of 15-200mmHg.[ncbi.nlm.nih.gov]
Altered Mental Status
  • This rare case of purulent pericarditis underscores the utility of bedside ultrasound in the ED and the complicated nature of altered mental status in intravenous drug users.[ncbi.nlm.nih.gov]
  • A 70-year-old woman presented to the emergency department with altered mental status. She was tachycardic and hypotensive with cardiomegaly on a chest X-ray.[ncbi.nlm.nih.gov]
  • Emergency physicians must maintain a high index of suspicion in making the diagnosis of CT as patients may present with vague symptoms such as neck or back pain, shortness of breath, fatigue, dizziness, or altered mental status, often without chest pain[ncbi.nlm.nih.gov]
  • Our patient was a 77year-old female admitted after presenting with general malaise, weakness, somnolence, altered mental status and urinary incontinence found to have CML (chronic myeloid leukemia) on confirmatory bone marrow biopsy after suspicions arose[ncbi.nlm.nih.gov]
  • mental status, oedema or waxing/waning if intermittently decompressing. [ 2 ] Dyspnoea, tachycardia, and tachypnoea.[patient.info]
Agitation
  • Once the patient was stable, and with the suspicion of HPS, contrast-enhanced echocardiography was performed using agitated saline, which revealed the presence of bubbles in left chambers 5 beats after they were detected in the right chambers.[revespcardiol.org]
Uremia
  • This commonly occurs as a result of chest trauma (both blunt and penetrating), but can also be caused by myocardial rupture, cancer, uremia, pericarditis, or cardiac surgery, and rarely occurs during retrograde aortic dissection, or while the person is[en.wikipedia.org]
  • […] iatrogenic (after cardiac surgery or intervention), trauma, malignancy, and idiopathic effusion. [7] [8] [9] Other common etiologies of large pericardial effusion include viral infection, radiation-induced pericarditis, collagen vascular disease, myxedema, uremia[online.epocrates.com]
  • […] pericardial cavity or between the heart and the pericardium Connective tissue disorders Drugs Infection Pericarditis : Inflammation of the pericardium Pneumopericardium: Air in the pericardial cavity Radiation therapy for cancer treatment Surgery Trauma Uremia[utswmedicine.org]
  • Any of the etiologies mentioned in pericardial effusion can result in cardiac tamponade if fluid accumulation occurs rapidly. acute pericarditis caused by uremia, metastasis, or Viruses such as Group B Coxsackie Viruses are the most common etiologies.[pathwaymedicine.org]
  • […] space is most often affected because of pericarditis, chest trauma, aortic dissection, scarring, hypothyroidism, lung cancer, heart tumors, kidney failure, cancer of the blood cells, radiation therapy, wounds to the heart, systemic lupus erythematosus, uremia[remedyland.com]
Incontinence
  • Our patient was a 77year-old female admitted after presenting with general malaise, weakness, somnolence, altered mental status and urinary incontinence found to have CML (chronic myeloid leukemia) on confirmatory bone marrow biopsy after suspicions arose[ncbi.nlm.nih.gov]

Workup

The following diagnostic modalities and tests are being implored among patients with cardiac tamponade:

  • Chest radiograph – Chest X-ray is routinely done identify the enlarging pericardial sac and isolate chest injuries.
  • Computed tomography (CT scan) – CT scan can effectively identify and measure the compression of the coronary sinus which is an early sign of cardiac tamponade [7].
  • Echocardiography – The two dimensional echocardiography can identify the obliteration of the spaces between the heart and the visceral side of the pericardium. Echocardiography can accurately measure the volume of fluid accumulation causing the cardiac tamponade. 
  • Electrocardiography (ECG) – The 12 leads ECG will exhibit sinus tachycardia, low voltage QRS complexes, PR segment depression, and electrical alterans. This characteristic changes are very typical of cardiac tamponade. 
  • Pulse oximetry – This will monitor the level of blood oxygenation and could detect pulsus paradoxus among patients with cardiac tamponade [8]. 
  • Cytopathologic studies – In some cases of pericardial effusion, a sample of fluid is being aspirated for laboratory study. This will identify the causative agent of the effusion and may also identify the antibiotic sensitivity of the pathogen [9].
Central Venous Pressure Increased
  • After 1 hour of allograft reperfusion, the cardiac index and blood pressure dropped markedly despite volume resuscitation, and the central venous pressure increased abruptly.[ncbi.nlm.nih.gov]
Electrical Alternans
  • Note that tachycardia, pulmonary embolism and ischemia may also cause electrical alternans. PQ segment depression. Sinus tachycardia. Refer to Figure 1. Figure 1. Electrical alternans in patient with cardiac tamponade.[ecgwaves.com]
  • The electrocardiogram showed low-voltage QRS complex with electrical alternans. An urgently performed bedside echocardiogram showed moderate pericardial effusion with a small right ventricular cavity with diastolic collapse.[ncbi.nlm.nih.gov]
  • Electrical alternans consists of beat-to-beat shifts in the QRS complex due to swinging of the heart in a large effusion.[medcomic.com]
  • We examined the diagnostic value of three ECG signs: low voltage, PR segment depression, and electrical alternans.[javed-abbas.tripod.com]
  • EKG 1,4 low voltage QRS, tachycardia, electrical alternans, PR depression, non-specific ST-T wave changes CXR 1,4 increased cardiac silhouette as compared to previous (most commonly utilized to evaluate for alternative diagnoses, e.g. pulmonary edema[emdocs.net]

Treatment

Patients with cardiac tamponade are always treated as a medical emergency. Patients are immediately attached for oxygen inhalation upon admission in the emergency room. Isotonic crystalloids are used to resuscitate the volume loss while the lower extremities are elevated. Inotropic agents like dobutamine is incorporated in the fluids to assists the pumping of the heart. Inpatients are subjected to pericardiocentesis and attached to a close drainage system to drain the reaccumulating fluids. Balloon pericardiotomy may also be instituted to restore the pericardial window. In extreme cases, an open thoracotomy with pericardiotomy is performed to directly drain the fluid and correct any anatomic defects [10].

Prognosis

Cardiac tamponade is a medical emergency. The failure to evacuate the pericardial fluid immediately can result into death. Effusion that gradually accumulates and does not reach a total volume of 150 ml may be averted when the underlying causes is immediately addressed. Penetrating injuries to the chest wall causing cardiac tamponade carry a grim prognosis.

Etiology

Cardiac tamponade can be caused by several medical conditions. Among these includes:

  • Bacterial or viral pericarditis
  • Hemorrhage within the pericardium
  • Tumor in the vicinity of the heart
  • Rupture of the heart muscles
  • Blunt trauma to the chest

Epidemiology

In the United States, the incidence of cardiac tamponade is estimated to be 2 cases per 10,000 population. Cardiac tamponade is more common in males than females with a ratio of 7:3 in children and 1.25:1 in adults. Traumatic causes and HIV infection are common causation in cardiac tamponade among young adults while renal failure and malignancies are more common in the elderly group.

Sex distribution
Age distribution

Pathophysiology

The basic pathophysiology of cardiac tamponade starts with the accumulation of fluid in the space between the pericardium and the heart. The common fluid accumulation in the pericardial space is usually hemorrhagic, chylous, serous, or serosanguinous in nature. The initial phase of the pericardial effusion increases the filling pressure of the heart ventricles making the ventricles physiologically stiffer. The continuous accumulation of fluid in the pericardial space increase the pericardial pressure beyond the ventricular filling pressure reducing the cardiac output significantly [1].

The progressive loss in functional cardiac output due to the cardiac tamponade diminishes the systemic venous return and consequently results in the collapse of the right atrium and right ventricles. Pericardial effusion as low as 150 ml accumulation can already greatly impede the cardiac output and function [2]. Although pericardial stretching with time can make the myocardium adaptive to this kind of restrictive insults, making the heart function normally and physiologically despite the presence of pericardial effusion.

Prevention

Chest trauma is one of the leading cause of cardiac tamponade, thus; the prudent use of seatbelts during driving greatly prevents the occurrence of accidental blunt trauma to the chest. Mild septicemia must be promptly treated to avoid the untoward complication of a bacterial or viral pericardial effusion. Patients with history of recurrent effusion in the pericardial space will benefit from the use of sclerosing agents to obliterate the potential space.

Summary

Cardiac tamponade occurs when the blood or fluids starts to build up between the myocardium and the pericardium that causes compression of the heart. The restrictive cardiac condition in cardiac tamponade limits the blood flow that is being pumped by the heart. Cardiac tamponade is a life-threatening condition that could be reversed rapidly with prompt and proper therapeutic interventions.

Patient Information

  • Definition: Cardiac tamponade is clinically defined as the accumulation of fluid in the pericardial space which alters cardiac filling and cardiac output.
  • Cause: Cardiac tamponade is caused by blunt and penetrating injuries to the chest. Tumors, infection, and myocardial rupture can also precipitate cardiac tamponade.
  • Symptoms: Cardiac tamponade is heralded by the Beck’s triad of hypotension, distended jugular veins, and distant heart sounds. Other signs of cardiac tamponade includes dyspnea, tachypnea, hepatomegaly, paradoxical pulses, and dysphoria.
  • Diagnosis: The diagnosis of cardiac tamponade may be ascertained by the use of chest X-ray, CT scan, 2D echocardiography, ECG, and cytopathologic studies.
  • Treatment and follow-up: This medical emergency is initially treated with oxygen inhalation and fluid resuscitation with inotropic agents. A surgical pericardiocentensis is done to drain the pericardial sac with the accumulating fluids. 

References

Article

  1. Reddy PS, Curtiss EI, Uretsky BF. Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol. Dec 15 1990; 66(20):1487-91.
  2. Saito Y, Donohue A, Attai S, Vahdat A, Brar R, Handapangoda I, et al. The syndrome of cardiac tamponade with "small" pericardial effusion. Echocardiography. Mar 2008; 25(3):321-7.
  3. Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does this patient with a pericardial effusion have cardiac tamponade? JAMA. April 2007; 297(16):9.
  4. Boltwood C, Rieders D, Gregory KW. Inspiratory tracking sign in pericardial disease. Circulation. 1984 ;( suppl II) 70:103.
  5. Ikematsu Y. Incidence and characteristics of dysphoria in patients with cardiac tamponade. Heart Lung. Nov-Dec 2007; 36(6):440-9.
  6. Sagristà-Sauleda J, Angel J, Sambola A, Alguersuari J, Permanyer-Miralda G, Soler-Soler J. Low-pressure cardiac tamponade: clinical and hemodynamic profile. Circulation. Aug 29 2006; 114(9):945-52.
  7. Gold MM, Spindola-Franco H, Jain VR, Spevack DM, Haramati LB. Coronary sinus compression: an early computed tomographic sign of cardiac tamponade. J Comput Assist Tomogr. Jan-Feb 2008; 32(1):72-7.
  8. Stone MK, Bauch TD, Rubal BJ. Respiratory changes in the pulse-oximetry waveform associated with pericardial tamponade. Clin Cardiol. Sep 2006; 29(9):411-4.
  9. Petcu DP, Petcu C, Popescu CF, Bataiosu C, Alexandru D. Clinical and cytological correlations in pericardial effusions with cardiac tamponade. Rom J Morphol Embryol. 2009; 50(2):251-6.
  10. Rylski B, Siepe M, Schoellhorn J, et al. Endoscopic treatment for delayed cardiac tamponade. Eur J Cardiothorac Surg. Sep 17 2009.

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Last updated: 2018-06-22 06:23