Cardiac tamponade is clinically defined as the accumulation of fluid such as blood in the pericardial sac which alters cardiac filling. Cardiac tamponade will usually present with hypotension, muffling of heart sounds, and accentuated neck veins. Because cardiac tamponade is a medical emergency, immediate attempts to evacuate the blood from the pericardium is of utmost priority to avoid mortality and further morbidity.
Presentation
The following symptomatology are observable in patients with cardiac tamponade:
- Dyspnea – This results with the ineffective pulmonary delivery of the blood by the heart.
- Hypotension – Blood pressure drops with the progressive decrease in the systemic venous return.
- Jugular enlargement – This vein engorges with the increasing jugular venous pressure [3].
- Chest wall injuries – These findings are eminent in patients who had undergone chest trauma.
- Tachypnea – This is a compensatory reaction of the lungs to oxygenate the blood in the advent of a decreasing cardiac output.
- Hepatomegaly – An acute or chronic passive congestion of the liver resulting to enlargement can occur due to the increasing venous pressure.
- Diminished or muffled heart sounds – This auscultatory finding is observable in cardiac tamponade patients due to the displacement of the heart secondary to the fluid accumulation.
- Paradoxical pulse (pulsus paradoxus) – The exaggerated pulse is generated due to the abrupt decrease in blood pressure during respiratory inspiration [4].
- Kussmaul sign – This sign refer to the increased distention of jugular vein due to the increase in venous pressure during inspiration.
- Dysphoria - This is a restless behavior exhibited by patients with cardiac tamponade as reaction to impending death [5].
Patients presenting with low blood pressure while in cardiac tamponade are unable to exhibit the Kussmaul sign, jugular venous distention, and pulsus paradoxus due to the hypovolemic state of the system. This type of cardiac tamponade is clinically referred to as low pressure tamponade occurring in 20% of all cardiac tamponade cases [6].
Entire Body System
- Large Pericardial Effusion
A large pericardial effusion with tamponade signs was verified by ultrasound and computerized tomography (CT) of the chest in a hemodynamically stable patient, and in the inability to evacuate the same, with pericardial fenestration, was successfully [ncbi.nlm.nih.gov]
Sagristà-Sauleda et al identified low-pressure tamponade in 20% of patients with cardiac tamponade. [16] They also reported low-pressure tamponade in 10% of large pericardial effusions. [emedicine.medscape.com]
- Ascites
Theoretically, as reported in only a single prior case, it can be caused by extrinsic compression from tense ascites. We present a case in which dynamic inferior wall collapse was secondary to increased abdominal pressure from tense ascites. [ncbi.nlm.nih.gov]
Reduced Cardiac Output: Results in hypotension and reactive tachycardia Left Heart Failure : Results in pulmonary edema and resultant dyspnea Right Heart Failure : Results in prominent increases in jugular venous pressure along with peripheral edema, ascites [pathwaymedicine.org]
[…] effusion (HIV, SLE, TB, malignancy, severe hypothyroidism, uremia, etc.), or resulting from trauma or cardiac surgery. 1 Presentation: Varies according to the size/rate of accumulation of the pericardial effusion: Subacute/chronic: Generalized malaise, ascites [emdocs.net]
[…] aortic dissection perforation from cardiac cath, pacer, PTCA, central line post CABG viral pericarditis neoplasm radiotherapy uremia CTD bacterial, TB Dressler/ myocardial rupture Clinical dyspnea fullness in abdomen due to liver and GI congestion ascites [mcgill.ca]
- Pallor
However, patient had bradycardia, and the other striking examination findings were coarse facies with pallor, madarosis, absent axillary and pubic hair and breast atrophy. Her blood sugar level was also low. [ncbi.nlm.nih.gov]
[…] initially asymptomatic Shortness of breath, especially while lying down ( orthopnea ) Beck's triad Hypotension Muffled heart sounds Distended neck veins Tachycardia, pulsus paradoxus Retrosternal chest pain Apical impulse difficult to locate or nonpalpable Pallor [amboss.com]
There was no associated pallor, cyanosis, tremors, or seizure-like activity. On regaining consciousness, she denied chest discomfort, dyspnea, palpitations, headache, leg pain, fever, or chills. [radcliffecardiology.com]
Physical examination The primary symptoms are related to shock: dyspnea, tachycardia, tachypnea, pallor, and cold extremities. The patient who has acute, rapid bleeding with cardiac tamponade appears critically ill and in shock. [medical-dictionary.thefreedictionary.com]
- Congestive Heart Failure
Congestive heart failure (CHF) (5%) Collagen vascular disease (5%): systemic lupus erythematosus, rheumatoid arthritis Infection (4%) HIV Bacterial infection: Staphylococcus aureus, Mycobacterium tuberculosis, Streptococcus pneumoniae (rare) Fungal infection [unboundmedicine.com]
These include pericarditis, malignancy, trauma (penetrating, blunt, postsurgical, and iatrogenic), uremia, connective tissue diseases, myocardial infarction, congestive heart failure, and radiation. [web.archive.org]
These include HIV-positive patients, patients with end-stage renal disease, those with known or occult malignancies, a history of congestive heart failure, tuberculosis, autoimmune diseases like lupus, or penetrating traumatic injury to central chest [ncbi.nlm.nih.gov]
Causes interference with heart action and subsequent sudden death or congestive heart failure. The heart shadow on radiography is enlarged, the heart sounds on auscultation are muffled. [medical-dictionary.thefreedictionary.com]
Respiratoric
- Dyspnea
This leads to jugular venous distention, visceral organ engorgement, edema, and elevated pulmonary venous pressure that causes dyspnea. [doi.org]
These patients often develop frequent ascites and present with clinical signs and symptoms similar to cardiac tamponade (tachycardia, hypotension and dyspnea). [ncbi.nlm.nih.gov]
- Cough
Symptoms typically include those of cardiogenic shock including shortness of breath, weakness, lightheadedness, and cough. [en.wikipedia.org]
Symptoms may include: Anxiety, restlessness Sharp chest pain that is felt in the neck, shoulder, back, or abdomen Chest pain that gets worse with deep breathing or coughing Problems breathing Discomfort, sometimes relieved by sitting upright or leaning [nlm.nih.gov]
Symptoms may arise gradually or rapidly, depending on fluid accumulation rate, and may range from dyspnoea, chest pain, cough, palpitations and orthopnoea, to fatigue, anxiety and confusion. [oncologypro.esmo.org]
[…] typically include one or more of the following: Fatigue or drowsiness Shortness of breath, rapid breathing, or difficulty breathing Lightheadedness Chest pain: That extends to the neck, shoulders, or abdomen Sharp or stabbing pain Pain that is worsened by coughing [winchesterhospital.org]
- Tachypnea
The child had tachypnea and mild subcostal retractions. Investigations revealed open safety-pin in lower esophagus, and pericardial effusion that later progressed to cardiac tamponade during handling of the safety pin by endoscope. [ncbi.nlm.nih.gov]
Other signs of cardiac tamponade includes dyspnea, tachypnea, hepatomegaly, paradoxical pulses, and dysphoria. [symptoma.com]
Tachycardia, tachypnea, and hepatomegaly are observed in more than 50% of patients with cardiac tamponade, and diminished heart sounds and a pericardial friction rub are present in approximately one third of patients. [emedicine.medscape.com]
Other frequent symptoms are pulsus paradoxus, pericardial friction sounds, tachycardia, tachypnea, weakened peripheral pulses, edema, cyanosis. Cardiac tamponade is seen in Video 1. Video 1. Cardiac tamponade. [ecgwaves.com]
- Dyspnea at Rest
We report a case of eosinophilic granulomatosis with polyangiitis in a 50-year-old Caucasian woman who presented with chest pain, dyspnea at rest, fever, and periorbital swelling. [ncbi.nlm.nih.gov]
Cardiovascular
- Hypotension
Of the 7 hypotensive or normotensive patients diagnosed with cardiac tamponade, 4 underwent successful pericardiocentesis while awaiting surgery. [ncbi.nlm.nih.gov]
Classically, patients have Beck's triad, which consists of the following: Hypotension Muffled heart tones Venous pressure increase (eg, neck vein distention) However, hypotension has multiple potential causes in trauma patients, muffled heart tones can [merckmanuals.com]
Pericardial effusion is initially asymptomatic, but cardiac tamponade has a distinct clinical presentation, including hypotension, tachycardia, jugular venous congestion, and pulsus paradoxus. [amboss.com]
- Pulsus Paradoxus
Pulsus paradoxus Pulsus paradoxus (or paradoxical pulse) is an exaggeration (>12 mm Hg or 9%) of the normal inspiratory decrease in systemic blood pressure. [emedicine.medscape.com]
This review explains the manifestations of tamponade, including a presentation in which the diagnostic finding of pulsus paradoxus is absent, and variant forms, such as low-pressure tamponade and regional tamponade. [doi.org]
Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers [scholar.harvard.edu]
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. [medbullets.com]
- Tachycardia
Despite compensatory tachycardia, the decrease in cardiac filling leads to a fall in cardiac output and to arterial hypoperfusion of vital organs. [doi.org]
Tachycardia, tachypnea, and hepatomegaly are observed in more than 50% of patients with cardiac tamponade, and diminished heart sounds and a pericardial friction rub are present in approximately one third of patients. [emedicine.medscape.com]
These patients often develop frequent ascites and present with clinical signs and symptoms similar to cardiac tamponade (tachycardia, hypotension and dyspnea). [ncbi.nlm.nih.gov]
Note that tachycardia, pulmonary embolism and ischemia may also cause electrical alternans. PQ segment depression. Sinus tachycardia. Refer to Figure 1. Figure 1. Electrical alternans in patient with cardiac tamponade. [ecgwaves.com]
- Heart Disease
Author information 1 Department of Cardiology, 4(th) Military Hospital, Wroclaw, Poland; Department of Heart Disease, Faculty of Health Sciences, Medical University in Wroclaw, Wroclaw, Poland. [ncbi.nlm.nih.gov]
Pericardial diseases. In: Zipes DP, Libby P, Bonow P, et al. Braunwald's heart disease: a textbook of cardiovascular medicine. 7th ed. Philadelphia: WB Saunders; 2005:1757-1781. [bestpractice.bmj.com]
It can also occur due to heart disease and heart attack. Symptoms One symptom of cardiac tamponade is a sharp, stabbing chest pain that radiates to the neck, shoulder, back or abdomen. [nhcs.com.sg]
Pericardial diseases. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019:chap 83. Little WC, Oh JK. [nlm.nih.gov]
- Pericardial Friction Rub
Tachycardia, tachypnea, and hepatomegaly are observed in more than 50% of patients with cardiac tamponade, and diminished heart sounds and a pericardial friction rub are present in approximately one third of patients. [emedicine.medscape.com]
At physical examination, tachycardia, decreased heart sounds, neck vein distension, peripheral oedema and pericardial friction rubs may be present. [oncologypro.esmo.org]
Evaluation: Perform a thorough H&P: VS abnormalities: persistent tachycardia (subacute/chronic) HEENT: JVD CV: muffled heart sounds, pericardial friction rub, peripheral edema Abdomen: hepatomegaly (subacute/chronic) Bedside echo 2,3 => Subxiphoid and [emdocs.net]
MEDICAL TREATMENT Patients with acute inflammatory signs (fever, chest pain, pericardial friction rub) should receive aspirin or non-steroid anti-inflammatory drugs. [doi.org]
Pericardial friction rub - present in 50% but may be transient. Acute tamponade leads to increased jugular venous pressure (JVP) - Beck's triad: jugular venous distension, hypotension and diminished heart sounds - rarely seen. [patient.info]
Liver, Gall & Pancreas
- Hepatomegaly
Evaluation: Perform a thorough H&P: VS abnormalities: persistent tachycardia (subacute/chronic) HEENT: JVD CV: muffled heart sounds, pericardial friction rub, peripheral edema Abdomen: hepatomegaly (subacute/chronic) Bedside echo 2,3 => Subxiphoid and [emdocs.net]
Other signs of cardiac tamponade includes dyspnea, tachypnea, hepatomegaly, paradoxical pulses, and dysphoria. [symptoma.com]
Tachycardia, tachypnea, and hepatomegaly are observed in more than 50% of patients with cardiac tamponade, and diminished heart sounds and a pericardial friction rub are present in approximately one third of patients. [emedicine.medscape.com]
Cardiac Output: Results in hypotension and reactive tachycardia Left Heart Failure : Results in pulmonary edema and resultant dyspnea Right Heart Failure : Results in prominent increases in jugular venous pressure along with peripheral edema, ascites, and hepatomegaly [pathwaymedicine.org]
Signs Distended neck veins, hypotension, tachycardia, tachypnoea and hepatomegaly. Muffled heart sounds. Pericardial friction rub - present in 50% but may be transient. [patient.info]
Neurologic
- Altered Mental Status
This rare case of purulent pericarditis underscores the utility of bedside ultrasound in the ED and the complicated nature of altered mental status in intravenous drug users. [ncbi.nlm.nih.gov]
mental status, oedema or waxing/waning if intermittently decompressing. [ 2 ] Dyspnoea, tachycardia, and tachypnoea. [patient.info]
- Agitation
The passage of at least five microbubbles from the right atrium into the adherent mass within three cardiac cycles following injection of the agitated saline would have been considered a positive test.) [radcliffecardiology.com]
Once the patient was stable, and with the suspicion of HPS, contrast-enhanced echocardiography was performed using agitated saline, which revealed the presence of bubbles in left chambers 5 beats after they were detected in the right chambers. [revespcardiol.org]
Confusion and agitation, cyanosis, tachycardia, and decreased urine output may all occur as cardiac output is compromised and tissue perfusion becomes impaired. [medical-dictionary.thefreedictionary.com]
Workup
The following diagnostic modalities and tests are being implored among patients with cardiac tamponade:
- Chest radiograph – Chest X-ray is routinely done identify the enlarging pericardial sac and isolate chest injuries.
- Computed tomography (CT scan) – CT scan can effectively identify and measure the compression of the coronary sinus which is an early sign of cardiac tamponade [7].
- Echocardiography – The two dimensional echocardiography can identify the obliteration of the spaces between the heart and the visceral side of the pericardium. Echocardiography can accurately measure the volume of fluid accumulation causing the cardiac tamponade.
- Electrocardiography (ECG) – The 12 leads ECG will exhibit sinus tachycardia, low voltage QRS complexes, PR segment depression, and electrical alterans. This characteristic changes are very typical of cardiac tamponade.
- Pulse oximetry – This will monitor the level of blood oxygenation and could detect pulsus paradoxus among patients with cardiac tamponade [8].
- Cytopathologic studies – In some cases of pericardial effusion, a sample of fluid is being aspirated for laboratory study. This will identify the causative agent of the effusion and may also identify the antibiotic sensitivity of the pathogen [9].
Cardiac Catheterization
- Central Venous Pressure Increased
After 1 hour of allograft reperfusion, the cardiac index and blood pressure dropped markedly despite volume resuscitation, and the central venous pressure increased abruptly. [ncbi.nlm.nih.gov]
QT, RR, ST Intervals
- ST Elevation
[…] myxedema, uremia, and tuberculosis (in endemic regions). [10] Postoperative tamponade is more common after valve surgery than after CABG, and occurs more often in patients undergoing anticoagulation. [11] There is a relatively low incidence (0.85%) of post-ST-elevation [online.epocrates.com]
Other ECG Findings
- Electrical Alternans
Electrical alternans – i.e the beat-to-beat variation i electrical amplitude – is the ECG hallmark of cardiac tamponade. [ecgwaves.com]
The electrocardiogram showed low-voltage QRS complex with electrical alternans. An urgently performed bedside echocardiogram showed moderate pericardial effusion with a small right ventricular cavity with diastolic collapse. [ncbi.nlm.nih.gov]
EKG 1,4 => low voltage QRS, tachycardia, electrical alternans, PR depression, non-specific ST-T wave changes CXR 1,4 => increased cardiac silhouette as compared to previous (most commonly utilized to evaluate for alternative diagnoses, e.g. pulmonary [emdocs.net]
Electrical alternans consists of beat-to-beat shifts in the QRS complex due to swinging of the heart in a large effusion. [medcomic.com]
We examined the diagnostic value of three ECG signs: low voltage, PR segment depression, and electrical alternans. [javed-abbas.tripod.com]
Treatment
Patients with cardiac tamponade are always treated as a medical emergency. Patients are immediately attached for oxygen inhalation upon admission in the emergency room. Isotonic crystalloids are used to resuscitate the volume loss while the lower extremities are elevated. Inotropic agents like dobutamine is incorporated in the fluids to assists the pumping of the heart. Inpatients are subjected to pericardiocentesis and attached to a close drainage system to drain the reaccumulating fluids. Balloon pericardiotomy may also be instituted to restore the pericardial window. In extreme cases, an open thoracotomy with pericardiotomy is performed to directly drain the fluid and correct any anatomic defects [10].
Prognosis
Cardiac tamponade is a medical emergency. The failure to evacuate the pericardial fluid immediately can result into death. Effusion that gradually accumulates and does not reach a total volume of 150 ml may be averted when the underlying causes is immediately addressed. Penetrating injuries to the chest wall causing cardiac tamponade carry a grim prognosis.
Etiology
Cardiac tamponade can be caused by several medical conditions. Among these includes:
- Bacterial or viral pericarditis
- Hemorrhage within the pericardium
- Tumor in the vicinity of the heart
- Rupture of the heart muscles
- Blunt trauma to the chest
Epidemiology
In the United States, the incidence of cardiac tamponade is estimated to be 2 cases per 10,000 population. Cardiac tamponade is more common in males than females with a ratio of 7:3 in children and 1.25:1 in adults. Traumatic causes and HIV infection are common causation in cardiac tamponade among young adults while renal failure and malignancies are more common in the elderly group.
Pathophysiology
The basic pathophysiology of cardiac tamponade starts with the accumulation of fluid in the space between the pericardium and the heart. The common fluid accumulation in the pericardial space is usually hemorrhagic, chylous, serous, or serosanguinous in nature. The initial phase of the pericardial effusion increases the filling pressure of the heart ventricles making the ventricles physiologically stiffer. The continuous accumulation of fluid in the pericardial space increase the pericardial pressure beyond the ventricular filling pressure reducing the cardiac output significantly [1].
The progressive loss in functional cardiac output due to the cardiac tamponade diminishes the systemic venous return and consequently results in the collapse of the right atrium and right ventricles. Pericardial effusion as low as 150 ml accumulation can already greatly impede the cardiac output and function [2]. Although pericardial stretching with time can make the myocardium adaptive to this kind of restrictive insults, making the heart function normally and physiologically despite the presence of pericardial effusion.
Prevention
Chest trauma is one of the leading cause of cardiac tamponade, thus; the prudent use of seatbelts during driving greatly prevents the occurrence of accidental blunt trauma to the chest. Mild septicemia must be promptly treated to avoid the untoward complication of a bacterial or viral pericardial effusion. Patients with history of recurrent effusion in the pericardial space will benefit from the use of sclerosing agents to obliterate the potential space.
Summary
Cardiac tamponade occurs when the blood or fluids starts to build up between the myocardium and the pericardium that causes compression of the heart. The restrictive cardiac condition in cardiac tamponade limits the blood flow that is being pumped by the heart. Cardiac tamponade is a life-threatening condition that could be reversed rapidly with prompt and proper therapeutic interventions.
Patient Information
- Definition: Cardiac tamponade is clinically defined as the accumulation of fluid in the pericardial space which alters cardiac filling and cardiac output.
- Cause: Cardiac tamponade is caused by blunt and penetrating injuries to the chest. Tumors, infection, and myocardial rupture can also precipitate cardiac tamponade.
- Symptoms: Cardiac tamponade is heralded by the Beck’s triad of hypotension, distended jugular veins, and distant heart sounds. Other signs of cardiac tamponade includes dyspnea, tachypnea, hepatomegaly, paradoxical pulses, and dysphoria.
- Diagnosis: The diagnosis of cardiac tamponade may be ascertained by the use of chest X-ray, CT scan, 2D echocardiography, ECG, and cytopathologic studies.
- Treatment and follow-up: This medical emergency is initially treated with oxygen inhalation and fluid resuscitation with inotropic agents. A surgical pericardiocentensis is done to drain the pericardial sac with the accumulating fluids.
References
- Reddy PS, Curtiss EI, Uretsky BF. Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol. Dec 15 1990; 66(20):1487-91.
- Saito Y, Donohue A, Attai S, Vahdat A, Brar R, Handapangoda I, et al. The syndrome of cardiac tamponade with "small" pericardial effusion. Echocardiography. Mar 2008; 25(3):321-7.
- Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does this patient with a pericardial effusion have cardiac tamponade? JAMA. April 2007; 297(16):9.
- Boltwood C, Rieders D, Gregory KW. Inspiratory tracking sign in pericardial disease. Circulation. 1984 ;( suppl II) 70:103.
- Ikematsu Y. Incidence and characteristics of dysphoria in patients with cardiac tamponade. Heart Lung. Nov-Dec 2007; 36(6):440-9.
- Sagristà-Sauleda J, Angel J, Sambola A, Alguersuari J, Permanyer-Miralda G, Soler-Soler J. Low-pressure cardiac tamponade: clinical and hemodynamic profile. Circulation. Aug 29 2006; 114(9):945-52.
- Gold MM, Spindola-Franco H, Jain VR, Spevack DM, Haramati LB. Coronary sinus compression: an early computed tomographic sign of cardiac tamponade. J Comput Assist Tomogr. Jan-Feb 2008; 32(1):72-7.
- Stone MK, Bauch TD, Rubal BJ. Respiratory changes in the pulse-oximetry waveform associated with pericardial tamponade. Clin Cardiol. Sep 2006; 29(9):411-4.
- Petcu DP, Petcu C, Popescu CF, Bataiosu C, Alexandru D. Clinical and cytological correlations in pericardial effusions with cardiac tamponade. Rom J Morphol Embryol. 2009; 50(2):251-6.
- Rylski B, Siepe M, Schoellhorn J, et al. Endoscopic treatment for delayed cardiac tamponade. Eur J Cardiothorac Surg. Sep 17 2009.