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Information ⬇

Author(s): John B. Chambers and David Sprigings

Consider cardiac tamponade if there is hypotension or breathlessness and a raised jugular venous pressure. Have a high index of suspicion in the presence of predisposing conditions (Table 54.1), notably cancer, or after central venous cannulation.

Priorities ⬆ ⬇

  1. Give oxygen, attach an ECG monitor and place an IV cannula. Your examination should include an assessment of pulsus paradoxus (Box 10.2). Pulsus paradoxus is an exaggeration of the normal inspiratory fall in systolic blood pressure to >10 mmHg. It may be palpable in the radial artery, with the radial pulse disappearing on inspiration.
  2. Obtain an ECG and chest X-ray to exclude other diagnoses, and an urgent echocardiogram (Table 54.2).
  3. If a pericardial effusion with clinical and echocardiographic signs of tamponade is confirmed, contact a cardiologist urgently to discuss pericardiocentesis. The technique of pericardial aspiration is described in detail in Chapter 120. If systolic pressure is <90 mmHg and the effusion cannot be drained immediately, treat with IV fluid together with an infusion of noradrenaline (Table 2.7) via a central line.

Further Management ⬆ ⬇

This is directed at the underlying cause (Table 54.1).

Consider purulent pericarditis if the patient is unwell with signs of sepsis. Start antibiotic therapy with advice from a microbiologist (e.g. IV vancomycin and ceftriaxone) after taking blood cultures.

Patients with malignant effusions will usually require further intervention to prevent recurrent tamponade, for example chemotherapy or creation of a pericardial window.

If the patient has pericardial effusion with tamponade complicating autoimmune disease, start prednisolone 30–40 mg PO daily, with gastroprotection.

Problems

Signs of tamponade but only small pericardial effusion (echo separation <10 mm)

This can occur with effusive-constrictive pericarditis in malignancy, autoimmune disease and after viral infection. Percutaneous drainage is potentially hazardous and may not relieve the symptoms. Seek urgent advice from a cardiologist.

Tamponade early after cardiac surgery

Discuss management with a cardiac surgeon. It may be more appropriate to drain the effusion surgically.

Tamponade with severely impaired left ventricular function

Total pericardiocentesis may lead to further ventricular dilatation. Limit drainage to 1L. Seek urgent advice from a cardiologist.

Further Reading ⬆

Ristić AD, Imazio M, Adler Y, et al. (2014) Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. European Heart Journal 35, 2279–2284. DOI: 10.1093/eurheartj/ehu217.

The Task Force for the diagnosis and management of pericardial diseases of the European Society of Cardiology (ESC) (2015) 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. http://www.escardio.org/static_file/Escardio/Guidelines/Publications/PERICA/2015%20Percardial%20Web%20Addenda-ehv318.pdf