Buildup of fluid around the heart
Medical condition
Cardiac tamponade
|
---|
Other names
| Pericardial tamponade
|
---|
|
A very large
pericardial effusion
resulting in tamponade as a result of bleeding from
cancer
as seen on ultrasound. Closed arrow ? the heart; open arrow ? the effusion
|
Specialty
| Cardiac surgery
|
---|
Symptoms
| Shortness of breath
, weakness,
lightheadedness
, cough
[1]
|
---|
Usual onset
| Rapid or more gradual
[2]
|
---|
Causes
| Cancer
,
kidney failure
,
chest trauma
,
pericarditis
,
tuberculosis
[2]
[1]
|
---|
Diagnostic method
| Symptoms and
ultrasound of the heart
[2]
|
---|
Treatment
| Drainage (
pericardiocentesis
,
pericardial window
,
pericardiectomy
)
[2]
|
---|
Frequency
| 2 per 10,000 per year (US)
[3]
|
---|
Cardiac tamponade
, also known as
pericardial tamponade
(
[4]
), is a compression of the
heart
due to
pericardial effusion
(the build-up of
pericardial fluid
in the
sac around the heart
).
[2]
Onset may be rapid or gradual.
[2]
Symptoms typically include those of
obstructive shock
including
shortness of breath
, weakness,
lightheadedness
, and cough.
[1]
Other symptoms may relate to the underlying cause.
[1]
Common causes of cardiac tamponade include
cancer
,
kidney failure
,
chest trauma
,
myocardial infarction
, and
pericarditis
.
[2]
[5]
Other causes include
connective tissues diseases
,
hypothyroidism
,
aortic rupture
,
autoimmune disease
, and complications of
cardiac surgery
.
[2]
[6]
In Africa,
tuberculosis
is a relatively common cause.
[1]
Diagnosis may be suspected based on
low blood pressure
,
jugular venous distension
, or quiet
heart sounds
(together known as
Beck's triad
).
[2]
[1]
[7]
A
pericardial rub
may be present in cases due to inflammation.
[2]
The diagnosis may be further supported by specific
electrocardiogram
(ECG) changes,
chest X-ray
, or an
ultrasound of the heart
.
[2]
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 tamponade.
[2]
Tamponade is a medical emergency.
[5]
When it results in symptoms, drainage is necessary.
[8]
This can be done by
pericardiocentesis
, surgery to create a
pericardial window
, or a
pericardiectomy
.
[2]
Drainage may also be necessary to rule out infection or cancer.
[8]
Other treatments may include the use of
dobutamine
or in those with
low blood volume
,
intravenous fluids
.
[1]
Those with few symptoms and no worrisome features can often be closely followed.
[2]
The frequency of tamponade is unclear.
[9]
One estimate from the United States places it at 2 per 10,000 per year.
[3]
Signs and symptoms
[
edit
]
Onset may be rapid (acute) or more gradual (subacute).
[10]
[2]
Signs of cardiac tamponade typically include those of
cardiogenic shock
including
shortness of breath
, weakness,
lightheadedness
, cough
[1]
and those of
Beck's triad
e.g. jugular vein distention, quiet heart sounds and
hypotension
. Other symptoms may relate to the underlying cause.
[1]
Other general signs of shock (such as
fast heart rate
,
shortness of breath
and decreasing
level of consciousness
) may also occur. 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
hypothyroidism
.
[1]
According to Reddy and co-authors, cardiac tamponade and its progression can be described in 3 different phases.
[11]
In phase I, the required filling pressure increases due to the high stiffness of the ventricles. This is because of the accumulation of pericardial fluid in the pericardial cavity. During phase II, the pericardial pressure exceeds the ventricular filling pressure caused by the further accumulation of pericardial fluid. This results in a decrease in cardiac input and output. A further decrease of cardiac input and output is typical in phase III of the progression of cardiac tamponade. This is caused by the equilibration of left ventricular filling and pericardial pressure, leading to “severe deterioration of end-organ perfusion.”
[11]
Some of the symptoms, as a consequence, include abdominal pain due to liver engorgement.
Causes
[
edit
]
Cardiac tamponade is caused by a large or uncontrolled
pericardial effusion
, i.e. the buildup of fluid inside the pericardium.
[12]
This commonly occurs as a result of
chest trauma
(both blunt and penetrating),
[13]
but can also be caused by
myocardial infarction
,
myocardial rupture
,
cancer
(most often
Hodgkin lymphoma
),
uremia
,
pericarditis
, or cardiac surgery,
[12]
and rarely occurs during retrograde
aortic dissection
,
[14]
or while the person is taking anticoagulant therapy.
[15]
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 circumstances.
[12]
Surgery
[
edit
]
One of the most common settings for cardiac tamponade is in the first 7 days after heart surgery.
[16]
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.
[17]
Pathophysiology
[
edit
]
The pericardium, the double-walled sac surrounding the heart, consists of a fibrous pericardium layer on the outside and a double-layered serous pericardium on the inside.
[18]
Between the two layers of the serous pericardium is the pericardial space, which is filled with lubricating serous fluid that prevents friction as the heart contracts.
[19]
The outer layer of the heart is made of fibrous tissue
[20]
which does not easily stretch, so once excess fluid begins to enter the pericardial space, pressure starts to increase.
[12]
Consequently, the heart becomes compressed due to its inability to fully relax.
[21]
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 volume
.
[12]
This causes the development of
obstructive shock
, which if left untreated may lead to
cardiac arrest
(often presenting as
pulseless electrical activity
).
[22]
The decrease in stroke volume can also ultimately lead to a decrease in cardiac output, which could be signaled by tachycardia and hypotension.
[21]
Diagnosis
[
edit
]
The three classic signs, known as
Beck's triad
, are
low blood pressure
, jugular-venous distension, and muffled
heart sounds
.
[24]
Other signs may include
pulsus paradoxus
(a drop of at least 10 mmHg in arterial blood pressure with inspiration),
[12]
and
ST segment
changes on the
electrocardiogram
,
[24]
which may also show low voltage
QRS complexes
.
[15]
Medical imaging
[
edit
]
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 collapse.
[15]
-
Apical ultrasound image of the heart in a person with cardiac tamponade. Note how the right atrial collapses during systole.
[23]
-
Ultrasound image of the
inferior vena cava
(IVC) in a person with cardiac tamponade. Note that the IVC is large and changes minimally with breathing.
[23]
Differential diagnosis
[
edit
]
Initial diagnosis of cardiac tamponade can be challenging, as there is a broad
differential diagnosis
.
[10]
The differential includes possible diagnoses based on symptoms, time course, mechanism of injury, patient history. Rapid onset cardiac tamponade may also appear similar to pleural effusions,
obstructive shock
, shock, pulmonary embolism, and
tension pneumothorax
.
[13]
[10]
If symptoms appeared more gradually, the differential diagnosis includes acute
heart failure
.
[25]
In a person with trauma presenting with
pulseless electrical activity
in the absence of hypovolemia and tension pneumothorax, the most likely diagnosis is cardiac tamponade.
[26]
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 people 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 people who are unconscious or who have convulsions at presentation.
[1]
Treatment
[
edit
]
Pre-hospital care
[
edit
]
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.
[
citation needed
]
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 person 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.
[
citation needed
]
Hospital management
[
edit
]
Initial management in hospital is by pericardiocentesis.
[13]
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 approach.
[27]
[28]
A left parasternal approach begins 3 to 5 cm left of the sternum to avoid the left internal mammary artery, in the 5th
intercostal space
.
[29]
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,
[13]
during which the pericardium is cut open to allow fluid to drain. Following stabilization of the person, surgery is provided to seal the source of the bleed and mend the pericardium.
[
citation needed
]
Following heart surgery, the amount of chest tube drainage is monitored. If the drainage volume drops off, and the blood pressure goes down, this can suggest a tamponade due to chest tube clogging. In that case, the person is taken back to the operating room for an emergency reoperation.
[
citation needed
]
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.
[
citation needed
]
Epidemiology
[
edit
]
The frequency of tamponade is unclear.
[9]
One estimate from the United States places it at 2 per 10,000 per year.
[3]
It is estimated to occur in 2% of those with stab or gunshot wounds to the chest.
[30]
References
[
edit
]
- ^
a
b
c
d
e
f
g
h
i
j
k
Spodick, DH (Aug 14, 2003). "Acute cardiac tamponade".
The New England Journal of Medicine
.
349
(7): 684?690.
doi
:
10.1056/NEJMra022643
.
PMID
12917306
.
- ^
a
b
c
d
e
f
g
h
i
j
k
l
m
n
o
Richardson, L (November 2014). "Cardiac tamponade".
Journal of the American Academy of Physician Assistants
.
27
(11): 50?51.
doi
:
10.1097/01.jaa.0000455653.42543.8a
.
PMID
25343435
.
S2CID
205395461
.
- ^
a
b
c
Kahan, Scott (2008).
In a Page: Medicine
. Lippincott Williams & Wilkins. p. 20.
ISBN
9780781770354
.
Archived
from the original on 2016-10-02.
- ^
"Tamponade | Meaning & Definition for UK English"
. Lexico.com. Archived from
the original
on March 4, 2021
. Retrieved
2022-08-24
.
- ^
a
b
"Cardiac Tamponade ? Injuries and Poisoning"
.
Merck Manuals Consumer Version
. Retrieved
1 May
2020
.
- ^
Schiavone, WA (February 2013).
"Cardiac tamponade: 12 pearls in diagnosis and management"
.
Cleveland Clinic Journal of Medicine
.
80
(2): 109?116.
doi
:
10.3949/ccjm.80a.12052
.
PMID
23376916
.
- ^
Khandaker, MH; Espinosa, RE; Nishimura, RA; Sinak, LJ; Hayes, SN; Melduni, RM; Oh, JK (June 2010).
"Pericardial disease: diagnosis and management"
.
Mayo Clinic Proceedings
.
85
(6): 572?593.
doi
:
10.4065/mcp.2010.0046
.
PMC
2878263
.
PMID
20511488
.
- ^
a
b
Sagrista-Sauleda, J; Merce, AS; Soler-Soler, J (26 May 2011).
"Diagnosis and management of pericardial effusion"
.
World Journal of Cardiology
.
3
(5): 135?143.
doi
:
10.4330/wjc.v3.i5.135
.
PMC
3110902
.
PMID
21666814
.
- ^
a
b
Bodson, L; Bouferrache, K; Vieillard-Baron, A (October 2011). "Cardiac tamponade".
Current Opinion in Critical Care
.
17
(5): 416?424.
doi
:
10.1097/mcc.0b013e3283491f27
.
PMID
21716107
.
S2CID
25236604
.
- ^
a
b
c
Stashko, Eric; Meer, Jehangir M. (2019),
"Cardiac Tamponade"
,
StatPearls
, StatPearls Publishing,
PMID
28613742
, retrieved
2019-08-02
- ^
a
b
Reddy PS, Curtiss EI, Uretsky BF. Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol. 1990 Dec 15;66(20):1487-91.
doi
:
10.1016/0002-9149(90)90540-h
.
PMID
2251997
.
- ^
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
978-0-7817-4988-6
.
- ^
a
b
c
d
Gwinnutt CL, Driscoll PA (2003).
Trauma Resuscitation: The Team Approach
(2nd ed.). Oxford: BIOS.
ISBN
978-1-85996-009-7
.
- ^
Isselbacher EM, Cigarroa JE, Eagle KA (Nov 1994).
"Cardiac tamponade complicating proximal (retrograde) aortic dissection. Is pericardiocentesis harmful?"
.
Circulation
.
90
(5): 2375?2378.
doi
:
10.1161/01.CIR.90.5.2375
.
PMID
7955196
.
- ^
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
978-0-19-852558-5
.
- ^
Carmona, Paula; Mateo, Eva; Casanovas, Irene; Pena, Juan J.; Llagunes, Jose; Aguar, Federico; De Andres, Jose; Errando, Carlos (2012). "Management of Cardiac Tamponade After Cardiac Surgery".
Journal of Cardiothoracic and Vascular Anesthesia
.
26
(2). Elsevier BV: 302?311.
doi
:
10.1053/j.jvca.2011.06.007
.
ISSN
1053-0770
.
PMID
21868250
.
- ^
Vistarini, Nicola; Gabrysz-Forget, Fanny; Beaulieu, Yanick; Perrault, Louis P. (2016).
"Tamponade Relief by Active Clearance of Chest Tubes"
.
The Annals of Thoracic Surgery
.
101
(3). Elsevier BV: 1159?1163.
doi
:
10.1016/j.athoracsur.2015.10.098
.
ISSN
0003-4975
.
PMID
26897195
.
- ^
Sharma, Nitish K.; Waymack, James R. (4 August 2021).
"Acute Cardiac Tamponade"
.
StatPearls
.
PMID
30521227
. Retrieved
22 November
2021
.
- ^
Vogiatzidis, Konstantinos; Zarogiannis, Sotirios G.; Aidonidis, Isaac; Solenov, Evgeniy I.; Molyvdas, Paschalis-Adam; Gourgoulianis, Konstantinos; Hatzoglou, Chrissi (18 March 2015).
"Physiology of pericardial fluid production and drainage"
.
Frontiers in Physiology
.
6
: 62.
doi
:
10.3389/fphys.2015.00062
.
PMC
4364155
.
PMID
25852564
.
- ^
Patton KT, Thibodeau GA (2003).
Anatomy & physiology
(5th ed.). St. Louis: Mosby.
ISBN
978-0-323-01628-5
.
- ^
a
b
Stashko, Eric; Meer, Jehangir M. (2021),
"Cardiac Tamponade"
,
StatPearls
, Treasure Island (FL): StatPearls Publishing,
PMID
28613742
, retrieved
2021-11-24
- ^
Standl, Thomas; Annecke, Thorsten; Cascorbi, Ingolf; Heller, Axel R.; Sabashnikov, Anton; Teske, Wolfram (2019-02-03).
"The Nomenclature, Definition and Distinction of Types of Shock"
.
Deutsches Arzteblatt International
.
115
(45): 757?768.
doi
:
10.3238/arztebl.2018.0757
.
PMC
6323133
.
PMID
30573009
.
- ^
a
b
c
Smith, Ben (27 February 2017).
"UOTW#78 - Ultrasound of the Week"
.
Ultrasound of the Week
.
Archived
from the original on 13 March 2017
. Retrieved
13 March
2017
.
- ^
a
b
Holt L, Dolan B (2000).
Accident and emergency: theory into practice
. London: Bailliere Tindall.
ISBN
978-0-7020-2239-5
.
- ^
Chahine, Johnny; Alvey, Heidi (2019),
"Left Ventricular Failure"
,
StatPearls
, StatPearls Publishing,
PMID
30725783
, retrieved
2019-08-02
- ^
American College of Surgeons Committee on Trauma (2007).
Advanced Trauma Life Support for Doctors, 7th Edition
. Chicago: American College of Surgeons
- ^
Shlamovitz, Gil (4 August 2011).
"Pericardiocentesis"
.
Medscape
.
Archived
from the original on 23 August 2011
. Retrieved
16 August
2011
.
- ^
Yarlagadda, Chakri (11 August 2011).
"Cardiac Tamponade Treatment & Management"
.
Medscape
.
Archived
from the original on 16 August 2011
. Retrieved
16 August
2011
.
- ^
Synovitz C.K., Brown E.J. (2011). Chapter 37. Pericardiocentesis. In Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T (Eds),
Tintinalli's Emergency Medicine: A Comprehensive Study Guide
, 7e. Retrieved September 19, 2014 from
"Chapter 37. Pericardiocentesis"
.
Archived copy
. The McGraw-Hill Companies. 2011.
Archived
from the original on 2016-03-04
. Retrieved
2014-09-20
.
{{
cite book
}}
: CS1 maint: archived copy as title (
link
)
- ^
Marx, John; Walls, Ron; Hockberger, Robert (2013).
Rosen's Emergency Medicine - Concepts and Clinical Practice
. Elsevier Health Sciences. p. 448.
ISBN
978-1455749874
.
Archived
from the original on 2016-10-02.
External links
[
edit
]
Classification
| |
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External resources
| |
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|
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Principles
| |
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Assessment
| |
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Management
| |
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Pathophysiology
| Injury
| |
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Mechanism
| |
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Region
| |
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Demographic
| |
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|
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Complications
| |
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