Cardiac tamponade

Cardiac emergency

1. CARDIAC TAMPONADE Mrs. D.Melba Sahaya Sweety.D M.Sc Nursing GIMSAR

2. Cardiac tamponade is a serious medical condition in which blood or fluids fill the space between the sac that encases the heart and the heart muscle. This places extreme pressure on your heart. The pressure prevents the heart’s ventricles from expanding fully and keeps your heart from functioning properly. So the heart can’t pump enough blood to the rest of your body when this happens. This can lead to organ failure, shock, and even death. INTRODUCTION

3. Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. Cardiac tamponade is a medical emergency.     Cardiac tamponade is cardiac dysfunction caused by external compression of heart by the accumulation of excessive contents in the pericardial space DEFINITION

4.  • Cardiac tamponade is the accumulation of excess fluid within the pericardial space, resulting in impaired cardiac filling, reduction in stroke volume, and epicardial coronary artery compression with resultant myocardial ischemia. This fluid, which can be blood , pus, or air in the pericardial sac. Accumulates fast enough and in sufficient quantity to compress the heart and restrict blood flow in & out of the ventricles. DEFINITION

5.  Incidence : 2-5 cases per 10000 • 2% penetrating injuries result into cardiac tamponade • • In adults male: female = 1.25:1 INCIDENCE

6. Cardiac tamponade develops due to pericardial effusion • Pericardial effusion: accumulation of excess fluid in pericardial space It may occur rapidly or insidiously Rapid pericardial effusion Trauma : both stabbing and blunt • Post myocardial infarction • Heart surgery (open heart surgery, CABG) • Aortic dissection • Drugs and medications ( antihypertensives   e.g. minoxidil , hydralazine , procainamide ) ETIOLOGY

7. Insidious pericardial effusion • Cancers ( lung or breast cancer) 30-60% • Infections (viral, bacterial, fungal) 5-10% • Uremic pericarditis (10-15%) • Hypothyroidism • Chronic inflammation of connective tissue (SLE, rheumatoid) high levels of radiation to the chest kidney failure ETIOLOGY

8. PATHOPHYSIOLOGY Pleural effusion due to various causes exert pressure in heart walls Impairs relaxation and filling of the ventricles Chambers do not fill properly  Less cardiac output (too little oxygen reaches the tissues)  Increase venous pressure  Hypotension, shock , Reflex tachycardia  ↑JVP hepatomegaly ascites peripheral edema Rales Systemic Congestion Pulmonary congestion

9. 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 CLINICAL MANIFESTATION

10.   Elevated venous pressure , Distended neck veins Kussmaul’s sign{distended neck veins} Hypotension Narrow pulse pressure Dyspnoea Cyanosis of lips and nails Restlessness and anxiety Pain in the right upper abdomen, Upset stomach Fever, for any infection CLINICAL MANIFESTATION

11.   Restlessness and anxiety Diaphoresis Muffled heart sounds Pulsus paradoxus Beck's triad (cardiology) Beck's triad. :- 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 CLINICAL MANIFESTATION

12.   History Collection :- Collect history regarding the etiological factors and symptoms Physical Examination :- Beck's triad, 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) ,Rub is a frequent finding in patients with inflammatory effusions DIAGNOSTIC EVALUATION

13. 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 , Combined P and QRS alternation is virtually specific for tamponade   DIAGNOSTIC EVALUATION

14. Echocardiogram :- This scan provides a detailed image of the heart, which may help to detect the fluid in the pericardial sac or a collapsed ventricle. Chest X-ray:- An X-ray of the chest shows if the heart is abnormally large or an unusual shape due to fluid build up.. DIAGNOSTIC EVALUATION

15. Computerized tomography (CT) scan:- A CT scan of the chest can confirm the presence of extra fluid in the pericardium. Magnetic resonance angiogram (MRA):- An MRA uses a magnetic field and radio waves to detect any abnormalities in how the blood flows through the blood vessels of the heart. DIAGNOSTIC EVALUATION

16. Heart failure Pulmonary edema Bleeding Shock Death COMPLICATION

17. The main aim of client with cardiac Tamponade is : 1. Save the patient life 2. improve the heart functions 3. Relive from symptoms   Treatment that are administered for cardiac tamponade include: 1. IV fluids to maintain normal BP 2. Antibiotics 3. Supplemental oxygen to reduce work load on the heart MEDICAL MANAGEMENT

18. 4.Bed rest and leg elevation 5. Inotropic drugs ( Dobutamine ) Mechanical ventilation with positive airway pressure should be avoided in patients with tamponade , because this further decreases cardiac output MEDICAL MANAGEMENT

19. PERICARDIOCENTESIS • Pericardiocentesis , also called a pericardial tap, is a surgical invasive procedure ( use both diagnostic and therapeutic purpose) in which abnormal or excessive fluid is removed from the pericardium sac the sac around your heart. Or Pericardiocentesis is the removal by needle of pericardial fluid from the sac surrounding the heart for diagnostic or therapeutic purposes. SURGICAL MANAGEMENT

20. NURSING MANAGEMENT Monitor strictly vital signs, especially respiratory frequency. Give the semi-Fowler position if not contraindicated. Give oxygen as indicated Monitor urine output hourly; a drop in urine output may indicate decreased renal perfusion as a result of decreased stroke volume secondary to cardiac compression. Continuously monitor ECG for dysrhythmia formation, which may result of myocardial ischemia secondary to epicardial coronary artery compression.

21. NURSING MANAGEMENT Monitor the BP every 5 to 15 minutes during the acute phase. Auscultation of breath sounds and heart sounds. Listen to the murmur. Maintain bed rest in a comfortable position during the acute period. Educate the patient about the disease condition and treatment Educate the patient about the pericardiocentesis Encourage the patient to ask questions

22. Ineffective Breathing Pattern related to hyperventilation as evidenced by Dyspnea .   Decreased cardiac output related to reduced ventricularfilling secondary to increased intrapericardial pressure as manifested by tachycardia. Activity intolerance related to shortness of breath and chest discomfort as manifested restlessness and fatigue NURSING DIAGNOSIS