Cardiac Tamponade Treatment & Management

  • Author: Chakri Yarlagadda, MD, FACC, FASNC, FSCAI; Chief Editor: Joseph L Fredi, MD   more...
 
Updated: Aug 11, 2011
 

Medical Care

Cardiac tamponade is a medical emergency. Preferably, patients should be monitored in an intensive care unit.

  • All patients should receive the following:
    • Oxygen
    • Volume expansion with blood, plasma, dextran, or isotonic sodium chloride solution, as necessary to maintain adequate intravascular volume: Sagrista-Saauleda et al noted significant increase in cardiac output after volume expansion.[15]
    • Bed rest with leg elevation: This may help increase venous return.
    • Inotropic drugs (eg, dobutamine): These can be useful because they do not increase systemic vascular resistance while increasing cardiac output.
  • Positive-pressure mechanical ventilation should be avoided because it may decrease venous return and aggravate signs and symptoms of tamponade.
  • Further medical care includes pericardiocentesis. Removal of pericardial fluid is the definitive therapy for tamponade and can be done by the following 3 methods.
    • Emergency subxiphoid percutaneous drainage: This is a life-saving bedside procedure. The subxiphoid approach is extrapleural; hence, it is the safest for blind pericardiocentesis. A 16- or 18-gauge needle is inserted at an angle of 30-45° to the skin, near the left xiphocostal angle, aiming towards the left shoulder. When performed emergently, this procedure is associated with a reported mortality rate of approximately 4% and a complication rate of 17%.
    • Echocardiographically guided pericardiocentesis (often performed in the cardiac catheterization laboratory): This is usually performed from the left intercostal space. First, mark the site of entry based on the area of maximal fluid accumulation closest to the transducer. Then, measure the distance from the skin to the pericardial space. The angle of the transducer should be the trajectory of the needle during the procedure. Avoid the inferior rib margin while advancing the needle to prevent neurovascular injury. Leave a 16-gauge catheter in place for continuous drainage.
    • Percutaneous balloon pericardiotomy: This can be performed using an approach similar to that for echo-guided pericardiocentesis, in which the balloon is used to create a pericardial window.
  • Patients should receive treatment of the underlying cause to prevent recurrence.
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Surgical Care

For a hemodynamically unstable patient or one with recurrent tamponade, provide the following care:

  • Surgical creation of a pericardial window: This involves the surgical opening of a communication between the pericardial space and the intrapleural space. This is usually a subxiphoidian approach with resection of xiphoid. Recently, a left paraxiphoidian approach with preservation of xiphoid has been described.[16] Open thoracotomy and/or pericardiotomy[3] may be required in some cases, and these should be performed by an experienced surgeon.
  • Pericardiocentesis or sclerosing the pericardium: This is a therapeutic option for patients with recurrent pericardial effusion or tamponade. Through the intrapericardial catheter, corticosteroids, tetracycline, or antineoplastic drugs (eg, anthracyclines, bleomycin) can be instilled into the pericardial space.
  • Pericardio-peritoneal shunt: In some patients with malignant pericardial effusions, creation of a pericardio-peritoneal shunt helps prevent recurrent tamponade.
  • Pericardiectomy: Resection of the pericardium (pericardiectomy) through a median sternotomy or left thoracotomy is rarely required to prevent recurrent pericardial effusion and tamponade.

Monaco et al investigated the efficacy of a modified, video-assisted thoracoscopic procedure in the treatment of 15 patients with cardiac tamponade.[17] Using a right hemithoracic approach, a 15-mm trocar was employed on the fourth right intercostal space on the anterior axillary, and a 10-mm trocar was used on the seventh right intercostal space on the median axillary line. Utilization of a 5-mm optic allowed 2 instruments, for the optic and for the endoscopic forceps, to be employed simultaneously using 1 trocar; this left the second trocar available for dissecting scissors. All patients underwent a pericardial resection equal to those achieved via anterolateral thoracotomy.

The pericardial effusion was effectively drained in all patients, with no intraoperative mortality or perioperative morbidity encountered. The investigators concluded, therefore, that the modified, video-assisted procedure employed in the study seems to be a feasible treatment for cardiac tamponade.

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Consultations

  • Hemodynamically stable patients - Cardiologist
  • Hemodynamically unstable patient - Cardiologist, cardiothoracic surgeon
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Activity

Initially, the patient should be on bed rest with leg elevation to increase the venous return. Once signs and symptoms of tamponade resolve, activity can be increased as tolerated.

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Contributor Information and Disclosures
Author

Chakri Yarlagadda, MD, FACC, FASNC, FSCAI  Director of Non-Invasive Cardiology, St Joseph Health Center; Invasive Cardiologist, Ohio Heart Institute

Chakri Yarlagadda, MD, FACC, FASNC, FSCAI is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Specialty Editor Board

Russell F Kelly  MD, Assistant Professor, Department of Internal Medicine, Rush Medical College; Chairman of Adult Cardiology and Director of the Fellowship Program, Cook County Hospital

Russell F Kelly is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ronald J Oudiz, MD, FACP, FACC, FCCP  Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, and American Thoracic Society

Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; LungRx Clinical Trials + honoraria; Bayer Grant/research funds Consulting

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Joseph L Fredi, MD  Assistant Professor of Medicine, Director of Acute MI Program, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center

Joseph L Fredi, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

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This anteroposterior-view chest radiograph shows a massive bottle-shaped heart and conspicuous absence of pulmonary vascular congestion. Reproduced with permission from Chest, 1996: 109:825.
A 12-lead electrocardiogram showing sinus tachycardia with electrical alternans. Reproduced with permission from Chest, 1996; 109:825.
Early diastolic collapse of right ventricular free wall (subcostal view)
Early diastolic collapse of right ventricular free wall (parasternal short-axis view at aortic valve)
Late diastolic collapse of right atrium (subcostal view)
Dilated inferior vena cava
 
 
 
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