eMedicine Specialties > Cardiology > Pericardial Disease

Cardiac Tamponade: Treatment & Medication

Author: Chakri Yarlagadda, MD, FACC, FASNC, Consulting Cardiologist, St Elizabeth Hospital, Youngstown, OH
Contributor Information and Disclosures

Updated: Oct 30, 2008

Treatment

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
    • 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.

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. Open thoracotomy and/or pericardiotomy 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.

Consultations

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

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.

Medication

The role of medication therapy in cardiac tamponade is limited. Occasionally, inotropic agents that do not increase the peripheral vascular resistance, such as dobutamine, may be used.

Adrenergic agonist agents

By stimulating beta-1 receptors in the heart, stroke volume and cardiac output are increased.


Dobutamine (Dobutrex)

Synthetic catecholamine and a direct inotropic agent that stimulates cardiac beta-receptors with minimal increase in systemic vascular resistance.

Adult

0.5-1 mcg/kg/min IV initially; titrate until desired therapeutic effect attained

Pediatric

Administer as in adults

Beta-adrenergic blockers antagonize effects; general anesthetics may increase toxicity

Documented hypersensitivity; idiopathic hypertrophic subaortic stenosis and atrial fibrillation or flutter

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Following myocardial infarction, use with extreme caution; hypovolemic state should be corrected before using this drug; ECG and blood pressure should be monitored continuously; pulmonary wedge pressure and cardiac output should be monitored, if possible; marked mechanical obstruction (severe valvular aortic stenosis) may prevent observation of improvement

More on Cardiac Tamponade

Overview: Cardiac Tamponade
Differential Diagnoses & Workup: Cardiac Tamponade
Treatment & Medication: Cardiac Tamponade
Follow-up: Cardiac Tamponade
Multimedia: Cardiac Tamponade
References
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References

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Further Reading

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Keywords

cardiac tamponade, pericardial tamponade, reduced ventricular filling, effusive-constrictive pericarditis, constrictive pericarditis, hemodynamic compromise, malignant disease, pericarditis, pericardial effusion, accumulation of fluid in the pericardial space, postmyocardial infarction, free wall ventricular rupture, Dressler syndrome, systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis, radiation therapy, antireflux surgery, pneumopericardium

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Contributor Information and Disclosures

Author

Chakri Yarlagadda, MD, FACC, FASNC, Consulting Cardiologist, St Elizabeth Hospital, Youngstown, OH
Chakri Yarlagadda, MD, FACC, FASNC is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, American Society of Nuclear Cardiology, and Heart Rhythm Society
Disclosure: Nothing to disclose.

Medical Editor

Russell F Kelly, MD, Program Director, Assistant Professor, Department of Internal Medicine, Division of Cardiology, Cook County Hospital, Rush Medical College
Russell F Kelly, MD is a member of the following medical societies: American College of Cardiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ronald J Oudiz, MD, Director of Pulmonary Hypertension, Associate Professor, Department of Medicine, Division of Cardiology, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA
Ronald J Oudiz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
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

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
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

George A Stouffer III, MD, Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center
George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
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