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Cardiac Tamponade

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Overview

Cardiac tamponade is a life-threatening emergency characterised by the accumulation of fluid, blood, pus, clots, or air in the pericardial space leading to restricted heart movement, reduced ventricular filling and haemodynamic compromise.

Epidemiology

  • Cardiac tamponade usually occurs following trauma or HIV in younger adults
  • Cardiac tamponade usually occurs due to malignancy and chronic kidney disease in more elderly people

Causes

Associated conditions

Drugs

  • Hydralazine
  • Isoniazid
  • Minoxidil

Other

  • Trauma e.g. surgery/accidents
  • Any procedure that perforates the cardiac tissue
  • Aortic dissection

Risk Factors

  • Malignancy
  • Aortic dissection
  • Pericarditis and its associated causes
  • Iatrogenic-related haemorrhages
  • Tuberculosis
  • Autoimmune disease
  • Hypothyroidism
  • Chronic kidney disease
  • Anticoagulation

Presentation

The classic features of cardiac tamponade are described with Beck’s triad:

  • Hypotension
    • There is a weak pulse and narrowed pulse pressure
  • Muffled heart sounds
  • Raised jugular venous pressure (JVP)

Other features may be:

  • Dyspnoea – seen in 90%
  • Pulsus paradoxus
    • >10mmHg drop in systolic blood pressure during inspiration
  • Tachycardia
  • Absent y descent in the JVP

Differential Diagnoses

Constrictive pericarditis

  • Patients have Kussmaul’s sign – increased JVP with inspiration which is generally absent in tamponade
  • Pulsus paradoxus is absent in constrictive pericarditis
  • Chest x-ray shows pericardial calcification

Investigations

All patients

  • ECG which may show:
    • Electrical alternans
  • Transthoracic echocardiogram – an essential test:
    • Shows large pericardial effusion or compression due to other causes e.g. masses
  • Chest x-ray:
    • Mainly to screen for other pathologies
    • A significant amount of fluid can accumulate in the pericardium before it is noticed on a chest x-ray
  • Cardiac troponins:
    • To assess for myocardial ischaemia
  • Full blood count (FBC):
    • May indicate inflammation or anaemia in chronic kidney disease
  • Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP):
    • Non-specific markers, may be elevated

Diagnosis

Diagnosis can be made clinically using Beck’s triad or can be made using a combination of symptoms and echocardiography findings.

Management

Overview

  • 1st line: urgent pericardiocentesis
    • The aspirate should be sent for culture and cytology to identify underlying causes

Urgent surgical drainage may be necessary in some scenarios.

Complications

  • Cardiac arrest
  • Organ hypoperfusion and failure
  • Recurrent or refractory pericarditis

Prognosis

  • The risk of death depends on how early the diagnosis and management are and the underlying cause of the tamponade
  • Early diagnosis and treatment are associated with a better outcome

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