CARDIAC

TAMPONADE
What is pericardium/pERICARDIAL?
• The pericardium is a thin double layered sac which encloses the
heart. The inner layer is called the visceral pericardium. It
contains small amount of fluid to cushion and lubricate the
heart as it contracts and expands. The outer layer is called the
parietal layer – a tougher layer attached to other body organs
like the diaphragm and cartilages between the ribs.
• There is about normally 20-50ml pericardial fluid in the
pericardial cavity
• Fluid is contained within the layers (in an area called the
pericardial space) and lubricates the two surfaces which
constantly rub together. There is about 20ml of fluid in this
pericardial space. When fluid builds up slowly, more than
200ml can be accompanied in the space, before any changes are
noticed.
• If the fluid builds up quickly, as little as 200ml can trigger
decompensation of the heart. Increased fluid results in increased
pressure, which can decrease the efficiency of the heart’s
pumping mechanisms and lower the body’s blood pressure.
What is Cardiac Tamponade?
pericardial tamponade
2 Types of cardiac tamponade
1. Acute cardiac tamponade (rapid accumulation of fluid, 100-200 ml fluid)
Causes:
• Chest trauma leading to rupture the free wall of the heart.
• Post mi
• Aortic dissection

2. Subacute/chronic cardiac tamponade (slow accumulation of fluid, up to 2000 ml fluid)

Causes:
• Neoplasia.
• Tuberculosis.
Risk Factors for Cardiac Tamponade
 There are many reasons why you might have a cardiac tamponade. The three
most common causes of cardiac tamponade are malignancy, uraemia (a toxic
condition resulting from kidney disease due to retention in the bloodstream of waste
products normally excreted in the urine), and irritation of the sac surrounding the
heart, due to unknown causes.

• Malignancy:
If you have cancer, fluid can accumulate in the pericardial sac surrounding the heart. This
fluid can build up and cause an increased pressure on the heart. Cancers can also cause bleeding
into the pericardial sac. This build up of blood in a confined space can further compromise the
heart.
• Penetrating or blunt injury:
A penetrating cardiac injury such as a stab wound to
the chest, can result in leakage of blood into the pericardial
sac (known as haemopericardium) and cause a rapid rise in
the pressure around the heart.
• Iatrogenic causes:
Occasionally, cardiac tamponade can be a result of
medical interventions and procedures. These include;
during central line placement, cardiac catheterization and
pacemaker insertion.
• Heart attacks (myocardial infarction):
After a heart attack, your heart muscle is weaker and more
likely to rupture around the site of tissue that has sustained injury.

• Infection:
Cardiac tamponade is often associated with pericarditis
(inflammation of the pericardial sac) caused by bacterial or viral
infections.
Clinical Examination of Cardiac Tamponade
When the doctor examines you, he or she may find the
following signs. In severe, acute situations, such as heart
trauma or rupture, there is a decrease in the pressure in your
arteries, an increase in the pressures of the veins and soft heart
sounds. Signs of cardiac tamponade are influenced by the
volume and rate of accumulation of fluid.
In circumstances where the rate of accumulation of fluid is slow, you
may have some signs such as; shortness of breath (especially when
lying down), liver enlargement and an increase in pressure in the
jugular vein (one of the main veins running down the side of the neck).
These signs are similar to those found in patients with heart failure.

The clinical triad of low blood pressure, increase in pressure in the

jugular vein and soft heart sounds is known as Beck’s triad. This is
very suggestive of cardiac tamponade.
Symptoms of Cardiac Tamponade
If you are affected by cardiac tamponade, some of the following symptoms
may be experienced:

•Anxiety,

•Shortness of breath,

•Fatigue,

•Chest discomfort or chest pain.

The pain may be: sharp, stabbing, radiating into the neck, back or
abdomen. Often it is worsened by deep breathing or coughing or
laughing.
•Palpitations (awareness of the heart beating
faster, stronger or at a different pattern
compared to usual)

•Feeling faint, light-headed.

In traumatic cardiac tamponade, there may be history of an
obvious penetrating chest injury. In these circumstances, you
may be acutely short of breath and may become confused and
drifting in and out of consciousness.

If you are affected by cardiac tamponade, you may also have a

history of medical diseases that can involve the sac surrounding
the heart, such as end-stage kidney disease.
How is Cardiac Tamponade Diagnosed?
These tests may be helpful in helping determine the presence and cause of cardiac tamponade.

Lab Studies:

•Full blood picture – blood is taken to measure the level of haemoglobin, red
cells, white cells, etc.

•Creatine kinase and isoenzymes – Enzymes released when heart muscle is

damaged, such as CK-MB, Troponin T/I, may be elevated.

•ECG – provides an electrical picture of the heart and can demonstrate low
voltages and/or alternating sizes of complexes.
Imaging Studies:

•Chest x-ray: The heart may appear large, globular or pear shaped with sharp
outlines. In cardiac tamponade, the chest x-ray may demonstrate an enlarged heart
shape after 200-250 mL of slow fluid accumulation. A normal cardiac picture seen
in patients with rapid accumulation of fluid or blood.

•Echocardiography: Most useful technique for demonstrating fluid in the pericardial

sac and can show collapse of the right pumping chamber of the heart (ventricle)
when the heart relaxes.

•Doppler: May show increased flow through specific valves in the heart.

•Magnetic Resonance Imaging: May detect blood or fluid around the heart
How is Cardiac Tamponade Treated?
The mainstay of treatment is drainage of the pericardial fluid
(pericardiocentesis), preferably under echocardiographic guidance, to
relieve the pressure.
Drainage of as little as 30-50ml of fluid may result in a dramatic
improvement in symptoms. If untreated, cardiac tamponade may lead to
pulmonary fluid collections, shock and even death. However, with
prompt recognition and treatment, most patients recover well. Patients
require close monitoring, usually in an intensive care unit.
Nursing interventions
When signs and symptoms related to cardiac tamponade are present, call a rapid
response, immediately notify the patient's healthcare provider, and prepare the
patient for diagnostic testing and therapeutic interventions.
Nurses have a primary role in monitoring patients for any deterioration in clinical
status.

 Keep patients with cardiac tamponade who are hypotensive on bed

rest with their legs elevated above heart level to increase venous
blood return to the heart.

 Patients who aren't hypotensive should be maintained on bed rest in

semi-Fowler position or leaning forward.
 Assess for respiratory distress and prepare to administer
supplemental oxygen as needed.
 Place the patient on continuous cardiac monitoring to
assess for dysrhythmias.
 Prepare for volume repletion with isotonic solutions such
as 0.9% sodium chloride solution, or inotropic support with
agents such as I.V. dobutamine, depending on the patient's
hemodynamic status.

 Monitor intake and output closely, especially hourly urine

outputs.
 If the patient undergoes percutaneous pericardiocentesis, monitor and
document the amount and characteristics of the drainage and obtain
specimens for lab analysis as prescribed.

 Monitor the catheter insertion site for signs and symptoms of

infection.

 Anticipate preparing the patient for emergent pericardiocentesis with

echocardiographic guidance.
Nursing diagnosis
Cardiac Tamponade References
1.Kasper DL. Harrisons Principles of Internal Medicine. New York: The McGraw-Hill
Companies; 2006
2.Kato N. Cardiac Tamponade [online]. 2006 [cited 2006 April 25th]. Available from: URL:
http://www.nlm.nih.gov/medlineplus/ency/article/000194.htm
3.Longmore JM, Hope RA, Longmore M. et al. Oxford Handbook of Specialties; USA: Oxford
University Press Inc. 2001
4.Valley VT, Fly CA. Pericarditis and Cardiac Tamponade. E-medicine [serial online]. 2005
[cited 23rd April 2006]. Available from URL: http://www.emedicine.com/EMERG/topic412.htm