QuestionSBA
QuestionChoice
Hypotension and raised jugular venous pressure may occur in pneumothorax, especially a tension pneumothorax. However, this is likely to be accompanied by sudden onset pleuritic chest pain, making it less likely. Therefore, a needle thoracostomy would not be appropriate
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e
Needle thoracostomy
QuestionChoice
This would be appropriate in acute heart failure. The patient does display some signs and symptoms in keeping with acute heart failure, such as dyspnoea, raised jugular venous pressure, and bibasal crepitations. However, this wouldn't explain the muffled heart sounds
32759
b
IV furosemide
QuestionChoice
The patient cannot talk in full sentences, which is one of the features of an acute severe asthma attack. However, this is less likely when considering the raised jugular venous pressure and bibasal crepitations without wheeze. Therefore, nebulised salbutamol would not be appropriate
32761
d
Nebulised salbutamol
QuestionChoice
The patient is displaying all the three hallmarks of Beck's triad. These are distended neck veins, hypotension and muffled heart sounds. When presenting acutely, the first presentation may be anxiety and fatigue. Dyspnoea, tachycardia and tachypnoea are also seen. Therefore, the definitive treatment is pericardiocentesis, where a needle is inserted into the pericardium to drain fluid
32758
a
Pericardiocentesis
QuestionChoice
Sertraline is a selective serotonin reuptake inhibitor (SSRI), which may be appropriate if the patient was suffering from a panic disorder. Although the patient is anxious, a panic disorder is less likely due to the pattern of the observations and the examination findings
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Sertraline
QuestionComment
i believe it should say "Beck's triad" rather than Back's
7680
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Dermis Cystic
QuestionComment
 (systolic blood pressure 111-219 mmHg) ???
22328
QuestionComment
maybe it's trying to hint at pulsus parodoxus with a rising and falling systolic BP, but those numbers (the cut-off is a variability of 10 mmhg) and the way it's written make absolutely no sense
22368
User
subscriber
Axillary Gas
QuestionComment
I think it's because on NEWS2 you don't score for hypertension until it's 220 systolic so the 'normal' values are indicating what is a NEWS2 of 0. Even though I probably wouldn't be chilled if someone had a systolic of 219. 
22992
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subscriber
Epidermis Pudendal
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subscriber
Hypertension Monoclonal
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
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Pericardiocentesis is the definitive treatment for cardiac tamponade, characterised by Beck's triad: distended neck veins, hypotension, and muffled heart sounds.
A 67-year-old woman attends A&E with anxiety and fatigue. She has been experiencing worsening shortness of breath and is unable to talk in full sentences. On examination, she has raised jugular venous pressure and bibasal crepitations, and it is difficult to hear heart sounds. Her observations are as follows:

- Temperature - 37.1 (36 - 38 degrees centigrade)
- Respiratory rate - 25 (12-20 breaths per minute)
- Heart rate - 110 (50-90 beats per minute)
- Blood pressure - 87/64 (systolic blood pressure 111-219 mmHg)
- Oxygen saturations - 92 (>96%)

What is the definitive treatment?
a