QuestionSBA
QuestionChoice
This patient has obstructive shock due to pericardial fluid that is reducing ventricular filling and thereby causing reduced cardiac output. Fluid challenges are more useful in the initial management of hypovolaemic (e.g. blood loss) and distributive shock (e.g. sepsis) but would not be as useful in this context
32264
b
500ml fluid challenge
QuestionChoice
Inotropes act to increase myocardial contractility and thereby increase cardiac output. They may be considered, but definitive management with pericardiocentesis should not be delayed
32266
d
Inotropes
QuestionChoice
Thoracocentesis is a procedure that aims to remove fluid or air from the pleural space. An emergency thoracocentesis is used for urgent decompression of a tension pneumothorax
32267
e
Emergency thoracocentesis
QuestionChoice
Cardiac tamponade is a medical emergency caused by the accumulation of fluid in the pericardial space, leading to reduced ventricular filling and haemodynamic compromise. Management is with pericardiocentesis which aims to remove the pericardial fluid
32263
a
Urgent pericardiocentesis
QuestionChoice
Although the patient has a raised JVP, they are not in congestive cardiac failure or pulmonary oedema. The raised JVP indicates increased right atrial pressure due to the pericardial fluid causing strain on the heart. As the patient is not fluid overloaded, there would be no benefit of giving diuretics. In this case, it would likely drop the patient's blood pressure further
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c
40mg IV furosemide
QuestionComment
Good question but the wording isn’t clear - surely it should be best next step in management as pericardiocentesis is not necessarily definitive (fluid can reaccumulate in the pericardium if inflammation doesn’t clear up)
22999
User
subscriber
Lazarus
QuestionComment
This definitive thing got me all kinds of confused.
25802
User
subscriber
Anterior Gallbladder
Concept
Chapter
# Summary
 
Cardiac tamponade is a life-threatening emergency that occurs when fluid (or occasionally gas or malignant tissue) accumulates in the pericardial sac, compressing the heart and impairing cardiac filling. It is often caused by trauma leading to bleeding into the pericardial sac, but may also result from pericarditis or malignancy. Beck's triad refers to the classical findings of a raised jugular venous pressure (JVP), hypotension and muffled heart sounds. Diagnosis can be reached rapidly with an echocardiogram. Pericardiocentesis is the usual emergency treatment. 

# Definition
 
Cardiac tamponade refers to the compression of the heart by fluid accumulation (often blood, occasionally gas or malignant tissue) in the pericardial sac. This compression impairs cardiac filling during diastole, compromising cardiac output and rapidly leading to cardiac arrest if untreated. 
 
# Aetiology
 
The commonest cause of acute cardiac tamponade is trauma, especially penetrating injuries. These may occur in road traffic accidents.

Iatrogenic causes (e.g. cardiothoracic surgery) can also lead to blood tamponading the heart. 

Other causes include:

- Pericarditis, which may be secondary to:
    - Malignancies
    - Myocardial infarction
    - Infections e.g. HIV, tuberculosis
    - Connective tissue diseases
    - Radiation
    - Chronic kidney disease
- Aortic dissection
- Medications (e.g. minoxidil, hydralazine)
- Cardiac perforation during diagnostic procedures
- Pneumopericardium (e.g. secondary to a gastropericardial fistula)

# Signs and Symptoms

The presentation of cardiac tamponade varies depending on the underlying cause and on how acutely it has developed. 

Symptoms include:

- Fatigue
- Dyspnoea
- Cold and clammy peripheries due to hypoperfusion
- Confusion due to reduced cardiac output

Signs include:

- Beck's triad (raised jugular venous pressure, hypotension and muffled heart sounds)
- Pulsus paradoxus (a decrease in systolic blood pressure by more than 10 mmHg during inspiration)
- Tachycardia
- Tachypnoea
- Altered mental state
- Hepatomegaly
- Pericardial friction rub
- Cyanosis
- JVP shows an absent Y descent (due to reduced diastolic filling of the ventricles)

# Differential Diagnosis

- **Acute heart failure** - overlapping features of dyspnoea and peripheral oedema, pulmonary oedema can occur in tamponade. Can be distinguished with echocardiography (showing ventricular dysfunction in heart failure).
- **Constrictive pericarditis** occurs when the pericardium is rigid or thickened (rather than fluid in the pericardial sac). It is usually chronic rather than acute, pericardial calcification may be seen on chest X-ray and Kussmaul's sign may be seen (when venous distention and pressure paradoxically increase in inspiration - rare in tamponade).
- **Pulmonary embolism** also causes sudden onset dyspnoea, associated with pleuritic chest pain and may have haemoptysis. Can also lead to cardiac arrest if massive; distinguished with echocardiography in the emergency setting and CTPA if stable enough for CT.
- **Tension pneumothorax** can also result from trauma and lead to rapid cardiac arrest, also causes acute dyspnoea but can be distinguished with examination findings of unilateral hyperresonance and reduced breath sounds, tracheal deviation to the contralateral side. 
 

# Investigations

**Bedside tests:**

- **ECG** may show electrical alternans, where the height of QRS complexes alternate due to movement of the heart in the pericardial space 

**Blood tests:**

- **Full blood count and CRP** looking for raised inflammatory markers in infective or inflammatory causes of tamponade
- **U&Es** as uraemia may cause pericarditis leading to tamponade
- **Coagulation screen** is important if attempting interventions such as pericardiocentesis
- **HIV testing** if this is a suspected cause of pericarditis
- **Group and Save** especially if bleeding is the cause of tamponade
- **Troponin** may be elevated in cardiac trauma or myocardial infarction

**Imaging:**

- An **echocardiogram** is the usual diagnostic test, looking for a pericardial effusion and evidence of impaired cardiac function
- **Chest X-ray** may show cardiomegaly; the epicardial fat pad sign may be seen (suggestive of pericardial effusion)
- **CT** sometimes detects evidence of tamponade (e.g. in the context of trauma)

**Other tests:**

- If the cause of tamponade is not clear, fluid drained from a pericardial effusion should be sent for culture and cytology

# Management

- Call for help - alert cardiology and intensive care
- Supportive therapies e.g. oxygen, IV fluids and inotropes
- Avoid positive-pressure ventilation as this may decrease venous return, worsening cardiac output
- Perform **pericardiocentesis** (aspirating pericardial fluid, usually at the bedside under echocardiography guidance)
- Open surgical drainage may be required in some cases e.g. ongoing intrapericardial bleeding
- Options for recurrent tamponade include percutaneous balloon pericardiotomy, pericardiodesis or pericardiectomy
- Treat the underlying cause e.g. infection, repair of traumatic injuries
 
# References

[Radiopaedia - Cardiac Tamponade](https://radiopaedia.org/articles/cardiac-tamponade)

[Patient UK - Cardiac Tamponade](https://patient.info/doctor/cardiac-tamponade)

[European Society of Cardiology - Cardiac Tamponade](https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Cardiac-tamponade-a-clinical-challenge)
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Emergency Management of Cardiac Tamponade
Topic
35
Cardiology
6453
Cardiac tamponade is a medical emergency requiring urgent pericardiocentesis to relieve fluid accumulation and restore haemodynamic stability.
A 45-year-old man with a diagnosis of myocarditis is assessed following an episode of hypotension on the ward. On assessment, he is tachycardic and tachypnoeic with a blood pressure of 90/50 mmHg. He has a raised jugular venous pressure (JVP) and his heart sounds are difficult to auscultate.

An urgent bedside ECHO shows cardiac tamponade.

Which of the following is the best definitive step in management?
a