Cardiac Tamponade

Question 1

What is cardiac tamponade?

Answer 1

• Accumulation of pericardial fluid, blood, pus or air within pericardial space
• Creates intra-pericardial pressure
• Restricts cardaic filling + reduces cardiac output
• A cardiac emergency + fatal if not quickly diagnosed/treated
• Diagnosis based upon clinical suspicion and supported by evidence of haemodynamic compromise on echo

DDx → constrictive pericarditis / restrictive cardiomyopathy / cardiogenic shock

Question 2

What are the risk factors for cardiac tamponade?

Answer 2

• Malignancy → lung + breast
• Aortic dissection → Type A
• Purulent pericarditis → rare
• Large idiopathic pericardial effusion
• Iatrogenic related haemorrhage
• TB

Question 3

Tamponade occurs at any age but most common in middle-aged + older people. In people from endemic regions, TB pericarditis remains prominent cause of effusion and tamponade.

In symptomatic patients, what are the most common causes of tamponade?

Answer 3

• Iatrogenic (post-cardiac surgery/intervention)
• Trauma
• Malignancy
• Idiopathic effusion

Others → viral infection, radiation-induced pericarditis, collagen vascular disease, myxoedema, TB

Question 4

What are the clinical features of tamponade?

Answer 4

• Beck’s triad → hypotension / raised JVP* / muffled heart sounds
• Dyspnoea
• Chest pain (atypical, non-exertional)
• Abdo pain (2^o hepatic congestion)

Other signs → tachycardia, pulsus paradoxus, electrical alternans (ECG)

*absent Y descent on JVP due to limited RV filling

Question 5

What are the key differences between constrictive pericarditis and cardiac tamponade?

Answer 5

Question 6

A pericardial effusion that raises intrapericardial pressure, reducing ventricular filling and thus dropping cardiac output can lead rapidly to cardiac arrest.

What is pulsus paradoxus and why does it occur?

Answer 6

Question 7

Which investigations can be done for cardiac tamponade?

Answer 7

• ECG → electrical alternas
• FBC → inflammatory pericarditis / anaemia in CKD
• ESR → inflammatory marker
• Cardiac enzymes → cardiac trauma / MI
• CXR → ?enlarged cardiac silhouette
• Transthoracic Echo (best) → invesrsion of the free wall of right atrium for over 1/3rd of systole

Question 8

With tamponade, there is a continuum of symptoms and haemodynamic effects. Pericardial effusions may resolve spontaneously or after treatment w/ NSAIDs or colchicine.

What is the management of a patient w/ haemodynamic instability?

Answer 8

Urgent pericardiocentesis