Cardiac Tamponade
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Introduction

Cardiac Tamponade is a condition where the heart become compressed by excess fluid in the pericardium. Compression causes reduced diastolic filling of the heart, which can cause cardiac arrest.

The pericardiac sac is normally a virtual space. This is enclosed by the pericardium.

Pericardium and Cardiac Tamponade
The Normal pericardial sac – size exaggerated in this diagram. Original image from Wikimedia commons. Author: Connexions

Causes of Cardiac Tamponade

  • Traumatic injury – particularly penetrating injury – can lead to accumulation of blood in the pericardial sac. This compresses the heart, and prevents diastolic filling, which leads to cardiac arrest. Cardiac Tamponade in a trauma setting an emergency and can quickly become life-threatening.
  • Pericarditis
  • Cancer
  • Iatrogenic – can occur after cardiothoracic surgery

Presentation

  • Becks Triad – occurs in about 1/3 of patients with cardiac tamponade
    • Hypotension
    • Distended Neck Veins
    • Muffled Heart Sounds
  • Tachycardia
  • Shortness of breath
  • Chest pain
  • Pulsus Paradoxus – systolic BP decreases >10mmHg on inspiration
  • Have a high index of suspicion in any patient with penetrating chest injury – especially they are not responsive to IV fluids and other basic investigations
  • FAST / bedside echo can diagnose without the need for other imaging (which may be time consuming)
  • It quickly causes cardiac arrest!

Management

  • Pericardiocentesis can be performed in the emergency setting in the peri-arrest scenario
    • Use a long 14 or 16G cannula attached a syringe
    • Insert at the angle of the xiphisternum and the left rib border – and aim for the ipsilateral (same side) scapula. Aspirate as you slowly advance. In reality this would often be performed US guided in the emergency department
    • Pericardiocentesis is sometimes attempted for suspected cardiac tamponade in the pre-hospital setting – but is rarely successful
  • Surgery may be indicated in some patients – this may be the formation of a pericardial window or could involve a pericardiectomy
  • Conservative management – may be attempted in some patients – albeit under very close monitoring (e.g. in the intensive care setting in a trauma patient)
  • Involving the cardiothoracics team (and trauma team if indicated) early in management and decision making is imperative

References

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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