Cardiac tamponade

Cardiac tamponade

1. Dr Md Ruhul Amin
Dept of Medicine
JRRMCH,SYLHET
Cardiac tamponade

2. Cardiac tamponade
•Also known as pericardial tamponade
•A medical emergency
•condition in which fluid, pus, clots, or gas
accumulates in the pericardium
•The elevated pericardial pressure puts
significant pressure on the heart, causing a
decrease in diastolic filling of the ventricles, and
hence in stroke volume. The end result is
ineffective pumping of blood, shock and
potentially death.

3. Cardiac tamponade
•The pericardial sac can expand to contain
a liter or more of fluid prior to tamponade
occurring.
•If the fluid occurs rapidly (as may occur
after trauma or myocardial rupture) as little
as 100 ml can cause tamponade.
•If 2L or more fluid accumulate then life-
threatening temponade occures.
• Coronary blood flow is reduced

4. Causes
•Hypothyroidism
•Trauma
•Pericarditis
•Iatrogenic trauma (during an invasive procedure)
• Ventricular rupture
• Myocardial rupture
• Cancer
•Uraemia
•During aortic dissection

5. Differential diagnoses
•Initial diagnosis can be challenging
•Tension pneumothorax
•Acute heart failure
•D/D’s of pulsus paradoxus-
1. Massive pulmonary embolism
2. Profound hemorrhagic shock
3. Other form of severe hypotension
4. Obstructive lung diseases

6. Symptoms
•Chest discomfort
•Pleuritic pain
•Tachypnea and dyspnea on exertion that
progresses to air hunger at rest are the key
symptoms
•Convulsions, unconscious
•Most patients are weak and faint at presentation
and can have vague symptoms such as anorexia,
dysphagia, and cough
•The initial symptom may also be one of the
complications of tamponade, such as renal failure

7. Diagnosis
Physical Examination
•Classical cardiac tamponade presents three signs, known as Beck's triad.
–Hypotension occurs because of decreased stroke volume,
- jugular venous distension due to impaired venous return to the heart
–muffled heart sounds due to fluid inside the pericardium
•Pulsus paradoxus (a drop of at least 10 mmHg in arterial blood pressure on
inspiration)
•There may also be general signs & symptoms of shock (such as tachycardia
, more than 90 beats) per minute breathlessness and decreasing
level of consciousness)
•Can be bradycardia? (uremia and patients with hypothyroidism)
• Most physical findings are equally nonspecific
•Rub is a frequent finding in patients with inflammatory effusions

8. Electrocardiographic Findings
•May be associated with ST segment
•low voltage QRS complexes
•In some cases, electrical alternans will be present in
which case the height of the QRS varies from beat to
beat
•Tachycardia will likely be present as well
•If the QRS complex is affected, every other QRS
complex is of smaller voltage, often with reversed
polarity
•Combined P and QRS alternation is virtually specific for
tamponade

9. Electrocardiographic Findings

10. Chest X Ray
•Tamponade can be diagnosed radiographically if
the fluid has accumulated slowly over time and if
the patient is stable enough to have had a chest
x-ray obtained. The chest x-ray will show an
enlarged globular heart.
•chest films may not be helpful initially, since at
least 200 ml of fluid must accumulate before the
cardiac silhouette is affected.

11. Echocardiography
•Demonstrates the collection of pericardial fluid
•Signs of more advanced tamponade include indentation
of the atrium and ventricle, and in later stages collapse
of these structures
•The location of the fluid should be characterized so that
the feasability and safety of pericardiocentesis can be
assessed
•The presence of loculations should be described
•Usually pericardiocentesis can be performed if there is
over 0.5 cm of anterior fluid
•The volume of most nonhemorrhagic effusions that
cause tamponade is moderate to large (300 to 600 ml)

12. Treatment
•Initial treatment usually be supportive
example administration of oxygen, and
monitoring
•General treatment for shock
•Some pre-hospital providers will have
facilities to provide pericardiocentesis

13. Hospital management
•Initial management in hospital is by
pericardiocentesis
•If facilities are available, an emergency
pericardial window may be performed
instead during which the pericardium is cut
open to allow fluid to drain. Following
stabilization of the patient, surgery is
provided to seal the source of the bleed and
mend the pericardium

14. variant forms
of cardiac tamponade
•Low-pressure tamponade occurs at diastolic pressures of 6 to 12
mm Hg and is virtually confined to patients with hypovolemia and
severe systemic diseases hemorrhage, or cancer, or in patients with
hypovolemia after diuresis
•Hypertensive cardiac tamponade with all the classic features of
tamponade, occurs at high and very high arterial blood pressures
(even over 200 mm Hg) and is ascribed to excessive beta-
adrenergic drive. Affected patients typically have had antecedent
hypertension.
•Regional cardiac tamponade occurs when any cardiac zone is
compressed by loculated effusions which are usually accompanied
by localized pericardial adhesions, especially after cardiac surgery
•Localized right atrial tamponade may also cause right-to-left hunting
through a patent foramen ovale or an atrial septal defect.

15. special problems
•Postoperative tamponade which is more
frequent after valve surgery than after coronary-
artery bypass surgery and is more frequent with
postoperative anticoagulant therapy, is due to
trauma-induced pericardial effusion and
bleeding.
•Late tamponade,occurring more than five days
postoperatively, must be suspected in any
patient in whom hypotension develops