Updated: 9/10/2019

Cardiac Tamponade

Topic
Review Topic
0
0
Questions
8
0
0
Evidence
6
0
0
Snapshot
  • A 45-year-old woman presents to the emergency room for chest discomfort and shortness of breath for the past few hours. She has a past medical history of systemic lupus erythematosus. Physical exam reveals hypotension, muffled heart sounds, distended jugular veins, and positive pulsus paradoxus. An echocardiogram (ECG) reveals low voltages and electrical alternans. Imaging shows an enlarged cardiac silhouette on radiography. A team is consulted for an emergent pericardiocentesis.
Introduction
  • Clinical definition
    • accumulation of fluid in the pericardial sac that restricts ventricular filling
  • Epidemiology
    • risk factors
      • pericarditis
      • malignancy
      • uremia
      • systemic lupus erythematosus
      • malignancy
      • tuberculosis
      • penetrating trauma
  • Etiology
    • pericardial effusion
    • hemorrhage into the pericardial sac
    • iatrogenic
  • Pathoanatomy
    • pericardium
      • the pericardium is an elastic sac that can stretch to accommodate normal cardiac volume expansion
        • however, if stretched beyond normal physiological expansion, the pericardium will stiffen
  • Pathogenesis
    • cardiac tamponade
      • increased pericardial pressure from the fluid accumulation causes compression of the cardiac chambers
        • this results in decreased cardiac output and blood pressure
    • pulsus paradoxus
      • normally, inhalation increases venous return → expands the right ventricle
        • in cardiac tamponade, the stiff pericardium will prevent the free wall from expanding
        • the only area for the right ventricle to expand is the interventricular septum, which will compress the left ventricle
          • compression of the left ventricle → decreased filling of the left heart → decreased blood pressure 
  • Associated conditions
    • ruptured ascending aortic dissection
    • ventricular free wall rupture from myocardial infarction
  • Prognosis
    • in acute cases, cardiac tamponade can develop rapidly
    • in chronic cases, cardiac tamponade will develop gradually, as the pericardium can adjust slowly to the increased pressure over time
Presentation
  • Symptoms 
    • chest pain
    • fatigability
    • often unresponsive to fluid resuscitation
  • Physical exam 
    • Beck triad
      • muffled heart sounds
      • jugular venous distention 
      • hypotension
    • cardiac
      • ↑ heart rate
      • pericardial rub if the patient has an inflammatory pericarditis
    • pulsus paradoxus 
      • a decrease in blood pressure > 10 mmHg during inhalation 
    • pulmonary
      • shortness of breath
      • lung fields are typically clear
    • extremities
      • cold and clammy
      • peripheral cyanosis
Imaging
  • Echocardiography
    • indications
      • for diagnosis of cardiac tamponade
      • most accurate test
      • for all patients
    • findings
      • diastolic collapse of the right heart
      • fluid in the pericardial space
      • swinging of the heart within the effusion
  • Radiography
    • indication
      • for all patients
    • views
      • chest
    • findings
      • enlarged cardiac silhouette seen only in subacute cardiac tamponade
      • in acute cases, pericardium will not accommodate build up of > 200 cc of fluid, which is required to appear enlarged on radiography
Studies
  • Electrocardiogram (ECG)
    • indications
      • for all patients
    • findings
      • low voltage
      • electrical alternans  
        • variations in the height of the QRS complex
        • from swinging of the heart in the chest
  • Right heart catheterization
    • indication
      • typically not performed as an initial test
    • findings
      • equilibration of pressures in all 4 chambers during diastole 
  • Making the diagnosis
    • based on clinical presentation, ECG, echocardiogram, and chest radiography
Differential
  • Constrictive pericarditis
    • distinguishing factors
      • also has pulsus paradoxus, but also presents with
        • Kussmaul sign
          • increase (or absence of decline) in jugular venous pressure with inhalation
        • pericardial knock
  • Tension pneumothorax
    • distinguishing factors
      • decreased or absent breath sounds
      • hyperresonant percussion
Treatment  
  • Management approach
    • all approaches focus on removal of the fluid in the pericardium
  • Conservative
    • close monitoring and volume expansion
      • indication
        • cardiac tamponade without hemodynamic compromise
        • modalities
          • serial echocardiographs
          • intravenous bolus of fluids
  • Procedural 
    • percutaneous pericardiocentesis  
      • indication
        • first-line treatment
  • Operative
    • surgical drainage
      • indications
        • patients with coagulopathy or need for biopsy
        • purulent pericarditis
        • traumatic cardiac tamponade
    • surgical drainage with pericardial window placement
      • indication
        • patients with chronic pericardial effusions
        • patients who decompensate
Complications
  • Death
 

Please rate topic.

Average 4.9 of 9 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M2.CV.4685) A 45-year-old male is brought into the emergency room by emergency medical services due to a stab wound in the chest. The wound is located superior and medial to the left nipple. Upon entry, the patient appears alert and is conversational, but soon becomes confused and loses consciousness. The patient's blood pressure is 80/40 mmHg, pulse 110/min, respirations 26/min, and temperature 97.0 deg F (36.1 deg C). On exam, the patient has distended neck veins with distant heart sounds. What is the next best step to increase this patient's survival? Review Topic

QID: 107358
1

Intravenous fluids

0%

(0/2)

2

Intravenous colloids

0%

(0/2)

3

Heparin

0%

(0/2)

4

Aspirin

0%

(0/2)

5

Pericardiocentesis

100%

(2/2)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 5

You have 100% on this question.
Just skip this one for now.

(M2.CV.4689) A 36-year-old female with a history of end stage renal disease secondary to poorly controlled type I diabetes on peritoneal dialysis presents to her nephrologist's office with chest pain, shortness of breath, and extreme fatigue. She has a history of inadequate dialysis due to poor compliance. In the office, the patient's vitals are BP: 94/58; HR: 90; RR: 20; T: 98.0 F. EKG is shown below (Figure A). The patient is immediately taken to the emergency department. What is the most likely diagnosis? Review Topic

QID: 107519
FIGURES:
1

Pericardial effusion

100%

(2/2)

2

ST elevation MI

0%

(0/2)

3

Non-ST elevation MI

0%

(0/2)

4

Hyperkalemia

0%

(0/2)

5

Pericarditis

0%

(0/2)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 1

You have 100% on this question.
Just skip this one for now.

(M2.CV.4045) A 36-year-old male is brought to the ED by fire-rescue after falling off a third-story scaffolding onto his back. On exam, HR is 126 bpm, BP is 80/56 mmHg, RR is 24 bpm, and temperature is 99.0 degrees Fahrenheit. Glascow Coma Score is 8, jugular veins are distended, and heart sounds are distant. Chest radiograph (Figure A) is shown. All of the following treatments may improve the patient's blood pressure EXCEPT: Review Topic

QID: 107017
FIGURES:
1

Catheter pericardiocentesis

11%

(2/19)

2

Aggressive volume expansion

32%

(6/19)

3

Positive pressure mechanical ventilation

21%

(4/19)

4

Urgent surgical exploration

26%

(5/19)

5

Placement of a pericardial window

5%

(1/19)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 3

You have 100% on this question.
Just skip this one for now.

(M2.CV.39) A 23-year-old female with a history of systemic lupus erythematous presents with 1 week of chest pain and shortness of breath. Exam is notable for increased respiratory rate, mild hypotension, and muffled heart sounds. Chest radiography is performed and the results are seen in figure F. Which of the following electrocardiograms would you expect to see in this patient? Review Topic

QID: 104045
FIGURES:
1

Figure A

58%

(11/19)

2

Figure B

21%

(4/19)

3

Figure C

5%

(1/19)

4

Figure D

0%

(0/19)

5

Figure E

5%

(1/19)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 1
ARTICLES (7)
Topic COMMENTS (14)
Private Note