Cardiac

tamponade
MOHD HATIF BIN KAMAIL
 • Triage to Red Zone
Mr MD •
•
Chest pain 5 days, most severe 4 am
SOB since 5 days, on exertion
• + othropnoea, no PND, no LL swelling
• No fever, no cough
• 74 y.o, Malay male underlying IHD, HPT, BPH, • o/e: alert, conscious, tachypnic, pale and lethargy
Dyslipidemia
• BP: 82/66, PR: 97, SPO2 100% under VMO2 60%,
• Ambulance call RR 32
• SOB, chest pain since 3am • Lungs: reduced a/e
• CVS: DRNM
• Took S/L GTN x2 not resolved • Abd: soft not tender
• BP: 96/70, PR 102, SPO2 90% under RA (95% • ECG: sinus tachycardia
under Face mask), Temp 36.2, GM 12.9, GCS • ABG under VMO2 60%:
E4V5M6 • pH: 7.37, PCO2: 39.5, PO2: 185, HCO3 22.6,
lac 1.5

• IMP: ACS in failure with underlying IHD

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• Then patient was given
• IVI noradrenaline
• T. aspirin 300mg, T Plavix 300mg
• S/c fondaparinoux 2.5mg
• IV Lasix 40+40 mg after BP picked up

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 • Post intubation patient remain hypotensive despite on
triple inotropes (noradrenaline, adrenaline, dopamine)
• Bedside POCUS:
• Pericardial effusion with organized clot
• Patient fitting, GTC, lasted for 5min, spontaneously • Good contractility
aborted • No RWMA< no RA/RV dilation, no diastolic
dysfunction
• Post ictal: restless, tachypnic
• Minimal B line L4, R4
• BP: 79/56, PR: 96, SPO2 71% under HFM
• Patient was reviewed by Dr Adli (Cardiologist) at RZ
• Lungs: bilateral ronchi
• IMP:
• CVS DRNM
• TRO Aortic dissection in cardiogenic shock
• Abd: soft not tender (DDx NSTEACS)
• Within minutes patient had cardiac arrest • Pericardial effusion likely secondary to 1 – no
echo evidence of cardiac tamponade
• CPR 2 min  ROSC
• For Trop, CTA and repeat ECHO
• Intubated for cerebral protection

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 Click icon to add picture

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 • Decide for pericardial tapping
• Drained 50cc hemoserous fluid

• Post tapping, BP picked up, able to taper down

• Inform family members regarding the current • Patient was admitted to ward by cardiothoracic
diagnosis, further management and guarded team – conservative management
prognosis
• Family members decide for DNAR • Patient succumb to death the next day
• COD: Severe cardiogenic shock secondary to
aortic dissection aneurysm

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Learning objectives
1. What is cardiac 2. How to evaluate?
tamponade?
Describe the pathology and •Explain how to evaluate a
classic presentation of a patient with cardiac
patient with cardiac tamponade.
tamponade

3. What are the 4. How to do

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 Click
CAUSES OF PERICARDIAL icon to add picture
EFFUSION
Likely to progress to cardiac tamponade 
1. Neoplastic diseases 
CARDIAC TAMPONADE 2. Infections (i.e. viral: EBV, CMV enteroviruses, HIV, bacterial,
especially tuberculosis) 
3. Iatrogenic hemopericardium 
4. Post-traumatic pericardial effusion 
5. Post-cardiotomy syndrome 
• History 6. Hemopericardium in aortic dissection and rupture of the heart post MI 
7. Renal failure 
• Physical examination
• ECG Rarely progressing to cardiac tamponade 
• Imaging 1. Systemic autoimmune disease
2.  Autoreactive pericardial effusions 
3. Hypo- or hyperthyroid 
4. Early and late pericarditis (Dressler's syndrome) in acute myocardial
infarction
5. Any other aetiology of pericardial disease (i.e. cholesterol pericarditis,
chylopericardium) 
 
Never progressing to cardiac tamponade 
1. Pericardial transudates caused by heart failure or pulmonary
hypertension 
2. Pericardial transudates in the last trimester of normal pregnancy 
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 Click icon to add picture

•Low QRS voltage

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 • RELATIVE CONTRAINDICATIONS:
PERCUTANEOUS • Coagulopathy
PERICARDIOCENTESIS • Plt < 50
• Surgical tamponade (Aortic dissection,
trauma, post MI wall rupture)

• INDICATIONS:
• Emergency =Cardiac tamponade
• Non Emergency =
• symptomatic moderate to large
effusion non-responsive to
medical therapy
• tuberculous, bacterial or
neoplastic pericarditis
• >2 cm in diastole

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 Click icon to add picture

Blind puncture
• Subxhyphoid

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 Click icon to add picture

US-Guided
• Static vs dynamic
• Approach: subxyhphoid, apical, left parasternal
• Confirmation

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 Click icon to add picture
SITE Description Disadvantages Advantages
Apical 1-2 cm lateral to apex beat Risk of ventricular puncture due to the The thicker left ventricle wall is
5th, 6th,or 7th ICS Needle over the proximity to the left ventricle. more likely to self-seal after
superior rib border Increased risk for pneumothorax for the puncture.
proximity to the left pleural space. Due to ultrasound not penetrating
air, using echocardiographic
guidance ensures avoidance of the
lung.
The path to reach the pericardium is
shorter.
Parasternal 5th left ICS close to sternal margin. Risk of pneumothorax and puncture of the Echocardiographic guidance, also
Needle perpendicular to the skin internal thoracic vessels (if the needle more with phase array probe, provides a
than 1 cm laterally). good visualisation of pericardial
structures.
Subxhyphoid Between the xiphisternum and left Steeper angle may enter the peritoneal Lower risk of pneumothorax.
costal margin. Once beneath the cavity, Medial direction increases the risk of
cartilage cage, lower the needle to RA puncture.
150-300 angle with the abdominal Left liver lobe may be transversed
wall directed towards left shoulder. intentionally if an alternative site is not
available.
The path to reach the fluid is longer.

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 Click icon to add picture

CONFIRMATION

Via agitated saline

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 Click icon to add picture

COMPLICATION
• Laceration of cardiac wall, coronary arteries,
intercostal vessels
• Puncture abdominal viscera or peritoneal cavity
• Pneumothorax
• Pneumopericardium
• Infection
• Arrhythmia
• Pericardial decompression syndrome
• Minor complication: transient vagal stimulation,
pleuropericardial fistula

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