Pathophysiology of cardiac tamponade

The physiology of cardiac tamponade and implications for patient management

Exceeding the limit of pericardial stretch, intrapericardial collections exert compression on the right heart and decrease preload. Compensatory mechanisms ensue to maintain hemodynamics in the face of a depressed stroke volume but are outstripped as disease progresses. When constrained within a pressurized pericardial space, the right and left ventricles exhibit differential filling mediated by changes in intrathoracic pressure. Invasive hemodynamics and echocardiographic findings inform on the physiologic effects. In this review, we describe tamponade physiology and implications for supportive care and effusion drainage.

Intra-cardiac motion detection catheter for the early identification of acute pericardial tamponade during invasive cardiac procedures

Objectives

To develop and test an intra-cardiac catheter fitted with accelerometers to detect acute pericardial effusion prior to the onset of hemodynamic compromise.

Background

Early detection of an evolving pericardial effusion is critical in ensuring timely treatment. We hypothesized that the reduction in movement of the lateral heart border present in developing pericardial effusions could be quantified by positioning an accelerometer in a lateral cardiac structure.

Methods

A "motion detection" catheter was created by implanting a 3-axis accelerometer at the distal tip of a cardiac catheter. The pericardial space of 5 adult sheep was percutaneously accessed, and pericardial tamponade was created by infusion of normal saline. The motion detection catheter was positioned in the coronary sinus. Intracardiac echocardiography was used to confirm successful creation of pericardial effusion and hemodynamic parameters were collected.

Results

Statistically significant reduction in acceleration from baseline was detected after infusion of only 40 ml of normal saline (p < 0.05, ANOVA). In comparison, clinically significant change in systolic blood pressure (defined as >10% drop in baseline systolic blood pressure) occurred after infusion of 80 ml of normal saline (107 ± 22 mmHg vs. 90 ± 12 mmHg p = 0.97, ANOVA), and statistically significant change was recorded only after infusion of 200 ml (107 ± 22 mmHg vs. 64 ± 5 mmHg, p < 0.05, ANOVA).

Conclusions

An intra-cardiac motion detection catheter is highly sensitive in identifying acute cardiac tamponade prior to clinically and statistically significant changes in systolic blood pressure, allowing for early detection and treatment of this potentially life-threatening complication of all modern percutaneous cardiac interventions.

Fatal iatrogenic cardiac tamponade due to central venous catheterization

Fatal adverse events caused by any health professional as consequence of malpractice are uncommon. In this work, the authors report a fatal cardiac tamponade associated with a peripherally inserted central catheter (PICC) by the right jugular vein that perforated the right atrium of the heart. The diagnosis of cardiac tamponade was not detected in hospital during the intrapericardial infusion of total parenteral nutrition and was only registered during the autopsy. The postmortem examination showed a milky liquid inside the pericardial cavity compatible with the total parenteral nutrition administered. The catheter in its migration in the cardiac chambers, mechanically perforated the inner wall of the endocardium between the trabeculae carneae, continued its course between the myocardial fibers until it was externalized. In conclusion, cardiac tamponade, although it is an extremely rare medical complication, has a high risk of fatality specially if peripheral rather than central veins were cannulated.

Concomitant intravascular and extravascular obstructive shock: a case report of cardiac angiosarcoma presenting with pericardial tamponade

Atraumatic pericardial tamponade and intracardiac masses are both recognized etiologies of acute obstructive shock. Pericardial tamponade, is a cardiovascular emergency commonly considered by emergency physicians and, as a result, evaluation for this process has been incorporated into standardized point of care ultrasound algorithms for assessing hypotension. Obstructive shock secondary to intracardiac tumors is an atypical clinical presentation, and although it is evaluated by the same ultrasound imaging modality, it is generally not considered or evaluated for in the emergency department setting. The concomitant presentation of these two pathologic processes is an extremely rare oncologic emergency. Existing literature on the subject is found in a small number of case reports with nearly no prior descriptions in emergency medicine references. In the right clinical context this unique presentation should be considered and evaluated for in the emergency department via point of care ultrasound modality to help guide in the management of the resulting obstructive shock.

When is tamponade not an echocardiographic diagnosis… Or is it ever?

Although cardiac tamponade remains a clinical diagnosis, echocardiography is an essential tool to detect fluid in the pericardial space. Interpretation of echocardiographic findings and assessment of physiologic and hemodynamic consequences of a pericardial effusion require a thorough understanding of pathophysiologic processes. Certain echocardiographic signs point toward the presence of cardiac tamponade: a dilated inferior vena cava (IVC), collapse of the cardiac chambers, an inspiratory bulge of the interventricular septum into the left ventricle (LV) (the "septal bounce"), and characteristic respiratory variations of Doppler flow velocity recordings. However, in certain circumstances (e.g., mechanical ventilation, post-surgical patients, and pulmonary hypertension), these echocardiographic signs can be missing, despite the presence of clinical tamponade. Failure to recognize a potentially life-threatening clinical condition due to the absence of corresponding echocardiographic findings can delay both diagnosis and life-saving treatment. Thus, in the context of critical care, echocardiography should only be used to confirm the presence of pericardial fluid or localized hematoma, and the diagnosis of tamponade should rely on clinical criteria.

Hemodynamics of cardiac tamponade during extracorporeal membrane oxygenation support in a patient with fulminant myocarditis

Fulminant myocarditis (FM) causes rapid onset severe heart failure requiring inotropes or mechanical circulatory support. Myocarditis is sometimes associated with pericardial effusion, however, how this effusion affects the hemodynamics in patients with FM under venoarterial extracorporeal membrane oxygenation (VA-ECMO) management has not been fully reported. We show a case of FM presenting with cardiac tamponade during VA-ECMO management. A 64-year-old female diagnosed as having FM showed a rapid hemodynamic collapse and that led to the application of VA-ECMO. Although her left ventricular ejection fraction did not improve despite proper hemodynamics management for several days, a pericardial effusion accumulated gradually. Apparent elevation of right atrial pressure and reduction of blood pressure were not observed, however, we performed pericardiocentesis because we were not able to wean off VA-ECMO. After the drainage of pericardial effusion, the blood pressure and cardiac output elevated as did the left ventricular ejection fraction. We successfully removed VA-ECMO and the patient was discharged without any complications. This is a case report in which a cardiac tamponade under VA-ECMO did not show typical signs and pericardiocentesis contributed to withdrawal of a VA-ECMO system. <Learning objective: Typical findings of cardiac tamponade are less likely to appear in patients with fulminant myocarditis under venoarterial extracorporeal membrane oxygenation management (VA-ECMO). Drainage of pericardial effusion delivers dramatic improvement in blood pressure, cardiac output, and left ventricular ejection fraction. When VA-ECMO cannot be weaned off, pericardiocentesis should be considered in patients with fulminant myocarditis who showed gradual accumulation of pericardial effusion.>.

Two episodes of cardiac tamponade in the same patient from removing pacing wires and a pericardial drain: A case report

A patient presented for an elective transcatheter aortic valve replacement with temporary transvenous pacing (TVP) wires placement per protocol. On postoperative day 1, the patient remained stable, so the wires were subsequently removed, after which the patient acutely decompensated, with transthoracic echocardiography revealing pericardial effusion. Emergent pericardiocentesis was performed, and a pericardial drain was placed. Three days later, the drain was removed; again, the patient acutely decompensated, requiring another emergent pericardiocentesis. Despite the relatively benign nature of TVP wires and pericardial drains, the possibility of cardiac tamponade should be kept in mind as a potential complication when they are being removed.

Echocardiographic approach to cardiac tamponade in critically ill patients

Cardiac tamponade should be considered in a critically ill patient in whom the cause of haemodynamic shock is unclear. When considering tamponade, transthoracic echocardiography plays an essential role and is the initial investigation of choice. Diagnostic sensitivity of transthoracic echocardiography is dependent on image quality, and in some cases a transoesophageal approach may be required to confirm the diagnosis. Knowledge of the pathophysiology and echocardiographic features of cardiac tamponade are essential for the practicing Intensivist. This review presents an approach to the recognition, diagnosis, and treatment of cardiac tamponade in critically ill patients.

The interface between monitoring and physiology at the bedside

Hemodynamic instability as a clinical state represents either a perfusion failure with clinical manifestations of circulatory shock or heart failure or 1 or more out-of-threshold hemodynamic monitoring values, which may not necessarily be pathologic. Different types of causes of circulatory shock require different types of treatment modalities, making these distinctions important. Diagnostic approaches or therapies based on data derived from hemodynamic monitoring assume that specific patterns of derangements reflect specific disease processes, which respond to appropriate interventions. Hemodynamic monitoring at the bedside improves patient outcomes when used to make treatment decisions at the right time for patients experiencing hemodynamic instability.

Cardiac tamponade in a woman with preeclampsia

Background: Preeclampsia is associated with alterations in maternal vascular permeability and can thus cause intravascular volume depletion and pathologic extravascular fluid accumulation. Although typically manifesting as peripheral edema or, in more severe cases, non-cardiogenic pulmonary edema, preeclampsia-associated vascular abnormalities can theoretically cause abnormal fluid collection in any extravascular space, including the pericardium.

Case: We report the case of a 30-year-old gravida 1 female admitted at 31 weeks 4 days’ gestation with mild preeclampsia, tachycardia, and dyspnea, whose initial workup was only significant for a small pericardial effusion. Over the course of the next 4 weeks, however, the effusion evolved into early cardiac tamponade that required expeditious pericardiotomy and cesarean delivery. The effusion virtually resolved over the first month postpartum.

Conclusion: The case describes a unique presentation of preeclampsia and suggests that echocardiography to evaluate for pericardial effusion be considered in cases of otherwise-unexplained cardiopulmonary symptoms in the setting of preeclampsia. If detected, cardiac tamponade should be managed in association with a multidisciplinary team familiar with the physiology of cardiac tamponade.

Traumatic right ventricular rupture following a horse kick

Cardiac tamponade is a life-threatening and time-critical emergency that requires early recognition and prompt management often alongside other resuscitation considerations. The use of ultrasound in the primary survey greatly assists in the early diagnosis allowing preparations for early definitive management to be made. An unusual case of right ventricular rupture following blunt trauma to the chest from a horse kick is discussed.

Unraveling the paradox of cardiac tamponade: case presentation and discussion of physiology

A 53-year-old man on warfarin for postoperative pulmonary embolism presented with chest pain and was found to be in cardiac tamponade due to an atraumatic haemopericardium. Findings of tamponade and a novel approach to the pathophysiology of pericardial disease to explain these finding are presented.

Pictorial review: computed tomography features of cardiovascular emergencies and associated imminent decompensation

Multi-detector computed tomography (MDCT) scanner is available in most hospitals and is increasingly being used as the first line imaging in trauma and suspected cardiovascular emergencies, such as acute coronary syndrome, pulmonary artery thrombo-embolism, abdominal aortic aneurysm and acute haemorrhage (Ryan et al. Clin Radiol 60:599-607, 2005). A significant number of these patients are haemodynamically unstable and can rapidly progress into shock and death. Recognition of computed tomography (CT) signs of imminent cardiovascular decompensation will alert the clinical radiologist to the presence of shock. In this review, the imaging findings of cardiovascular emergencies in both acute traumatic and non-traumatic settings with associated signs of imminent decompensation will be described and illustrated.

Bedside emergency cardiac ultrasound in children

Bedside emergency ultrasound has rapidly developed over the past several years and has now become part of the standard of care for several applications. While it has only recently been applied to critically ill pediatric patients, several of the well-established adult indications may be applied to pediatric patients. One of the most important and life-saving applications is bedside echocardiography. While bedside emergency ultrasonography does not serve to replace formal comprehensive studies, it serves as an extension of the physical examination. It is especially useful as a rapid and effective tool in the diagnosis of pericardial effusions, tamponade and in distinguishing potentially reversible causes of pulseless electrical activity from asystole. Most recently, left ventricular function and inferior vena cava measurements have proven helpful in the assessment of undifferentiated hypotension and shock in adults and children. Future research remains to be carried out in determining the efficacy of bedside ultrasonography in pediatric-specific pathology such as congenital heart disease. This article serves as a comprehensive review of the adult literature and a review of the recent applications in the pediatric emergency department. It also highlights the techniques of bedside ultrasonography with examples of normal and pathologic images.

Prehospital mechanical ventilation of a critical cardiac tamponade

Mechanical ventilation of a critical cardiac tamponade is a high-risk situation that can lead to asystolic cardiac arrest. We report a prehospital mechanical ventilation of a penetrating cardiac injury complicated with tamponade. Onset diagnosis of the circulatory arrest allowed by prehospital continuous ultrasonography led to earlier initiation of the resuscitation and might have favored successful outcome. Electrocardiographic signs are too late to diagnose circulatory arrest.

[The etiology, differential diagnosis and therapy of pericardial effusion]

Considerable etiologic factors may lead to the development of pathologic pericardial effusion. In many cases these factors remain unidentified, the fact which leads to difficulties in choosing the appropriate therapeutic strategy. The therapy of pericardial effusion associated with purulent pericarditis must be different than that effusion developed as a consequence of neoplasm or autoimmune disease. The cytological examination of the fluid and the hystological examination of the pericardial tissue play an important role in identifying the accurate etiologic diagnosis. In case of recurrent pericardial effusions, performing pericardioperitoneal, pericardiopleural shunt or pericardial window may be indicated. This palliative solution serves to prevent the development of pericardial tamponade and its haemodynamic consequences.

Pericardial tamponade in patients with central venous catheters

Cardiac (pericardial) tamponade occurs when the pressure of the fluid within the pericardial sac is high enough to impair the venous return to the heart. Cardiac tamponade can occur during central venous catheter placements. Nursing members of a central vascular catheter placement team benefit from quickly recognizing this clinical situation and understanding the appropriate clinical response. A methodical approach to this potentially fatal condition can greatly increase patient safety. This article reviews this condition, its clinical presentation and diagnosis, and strategies for avoiding central vascular access-associated tamponade.

Pulsus paradoxus in cardiac tamponade: a pathophysiologic continuum

Pulsus paradoxus has interested physicians for more than a century. Since McGregor's comprehensive New England Journal of Medicine article in 1979, there have been no updated reviews; accordingly, we review pulsus paradoxus based on the clinical and physiologic literature and personal experience.

Echocardiography in the diagnosis and management of pericardial disease

This review covers the role of echocardiography in the diagnosis and management of the main pericardial disorders. The sensitivity of echocardiography in detecting pericardial fluid is very high and this technique allows the detection of effusion as well as the definition of the size of effusion (small, moderate and severe). The evaluation of the pericardial sac should be carefully performed through all the echocardiographic windows, differentiating diffuse from loculated (regional) effusions. Several echocardiographic and Doppler signs allow an accurate diagnosis of cardiac tamponade. The role of echocardiography is extremely important in atypical clinical presentation such as in patients in the postoperative period after cardiac surgery. Moreover, drainage of the effusion is mandatory in the presence of cardiac tamponade and in this regard echo-guided pericardiocentesis is the gold-standard method. Finally this review covers the echocardiographic diagnosis of pericardial cysts and masses and constrictive pericarditis.

Outcomes of clinically significant idiopathic pericardial effusion requiring intervention

There is a paucity of outcome data on patients with idiopathic pericardial effusion requiring intervention. All patients who had clinically significant pericardial effusion confirmed by echocardiography and requiring interventions between 1979 and 2000 were identified through the Echo-guided Pericardiocentesis Registry and Echocardiography and Surgical Databases. Clinical data and outcomes were obtained by review of medical records and surveys. The study population consisted of 92 patients (mean age 59 +/- 15 years). Five patients were referred directly for pericardiectomy (3 had effusion in the context of chronic relapsing pericarditis, 2 had effusive constrictive disease), and 87 underwent echo-guided pericardiocentesis as their initial treatment. In 47 of these patients, primary management involved extended pericardial catheter drainage, which was associated with a trend to lower recurrence rates than in those without catheter drainage (p = 0.052). Three patients had transient right ventricular entry with no sequelae, and 7 patients (8%) later had surgical pericardiectomy because of the recurrence of effusion, 2 of whom were also found to have evidence of effusive constrictive disease during surgery. One patient had bleeding after pericardiectomy that required repeat thoracotomy. Mean follow-up of the cohort was 3.8 +/- 4.3 years. For most patients with clinically significant idiopathic pericardial effusion requiring intervention, echo-guided pericardiocentesis was the definitive treatment. Pericardiectomy was necessary for patients in whom effusion occurred in the context of effusive constrictive disease, chronic relapsing pericarditis, or recurrent effusion despite pericardiocentesis. The prognosis for the cohort was favorable, and survival did not appear to differ from that of the general population (p = 0.372).

Pericardial tamponade complicating central venous interventions

Cardiac tamponade is defined as an accumulation of fluid within the pericardial sac that is large enough to impair the diastolic filling of the ventricles. There are numerous causes, including cardiac disease, malignancy, and trauma (penetrating, blunt, and iatrogenic). With increasing complexity of percutaneous endovascular interventions, interventional radiologists must learn to recognize the preexisting and iatrogenic presence of cardiac tamponade during procedures and be familiar with its treatment. Two cases of pericardial tamponade complicating central venous interventions are described. In addition, the clinical condition is discussed and its diagnosis and treatment are reviewed.

Lymphatic transport of pericardial effusate in sheep

In this report, we quantified fluid loss from the pericardial cavity during simulated saline effusions and determined what proportion of this loss occurred through lymphatics. Fifty or 100 ml of Ringers lactate solution [containing 0.5% sheep albumin and (131)I-human serum albumin (HSA)] was injected into the pericardial cavity of sheep. Pericardial pressures, systemic arterial pressures, and plasma/pericardial fluid concentrations of the radioactive tracer were measured. Lymph transport of pericardial fluid was estimated from the plasma recovery of tracer using a mass balance equation. Plasma recoveries were corrected for tracer loss using a coefficient of elimination calculated from the plasma disappearance curve of intravenously administered (125)I-HSA. Over 4 h, 27.6 +/- 4.9 (+/-SE) and 36.7 +/- 4.2 ml were lost from the pericardial cavity in the 50- and 100-ml effusion series, respectively, of which 5.2 +/- 0.8 (20.2 +/- 3.8% of volume lost) and 7.7 +/- 1.6 ml (21.5 +/- 3.3% of volume lost) could be attributed to lymphatic transport. We conclude that lymphatic transport is one of the factors that contribute to pericardial "reserve" function by helping to restore pericardial fluid volume to resting levels.

Spinal cord infarction caused by cardiac tamponade

This article describes a 16-yr-old male patient who went into shock and cardiac arrest 2 wk after surgical repair of an atrial septal defect. Cardiac tamponade was diagnosed and promptly treated, and his hemodynamic status stabilized 4 hr after the initial presentation of shock; however, paraplegia was found when the patient regained consciousness. Physicians should be alert to a possible diagnosis of spinal cord infarction in patients with complications of cardiovascular surgery, particularly when a new onset of neurologic symptoms or signs occurs.

Pathophysiologic mechanisms in pericardial disease

The pericardium influences cardiac performance indirectly, but pathologic conditions may have profound effects on cardiac function. In recent years, several imaging modalities have been useful, both clinically and in understanding the pathophysiology of pericardial diseases. Rising pericardial pressures progressively reduce the average transmural pressure of the right and subsequently left cardiac chambers, compromising filling and output. This has become more relevant today, with the increased incidence of cardiac tamponade, attributed to the increased use of antiplatelet agents in combination with a more widespread use of invasive devices. On another front, although an uncommon diagnosis, constrictive pericarditis may be missed despite the excellence of a variety of noninvasive methods, and remains a difficult one to make.Introduction

Analysis of left ventricular systolic function during elevated external cardiac pressures: an examination of measured transmural left ventricular pressure during pressure-volume analysis

BACKGROUND

Variations or disturbances in intrathoracic and extracardiac pressures (ECP) occur in critically ill and anaesthetised patients. There are uncertainties concerning the analysis of left ventricular pressure-volume relationship (LVPVR) and the calculation of systolic function parameters when conducted without reference to transmural left ventricular pressure (LVPtm) in the setting of elevated ECP.

METHODS

In 7 anaesthetised adult pigs, we measured LVPVR using conductance volumetry and tip manometry along with measurement of pericardial and other intrathoracic pressures. Experimental pericardial infusion and pleural insufflation were performed. Transient controlled preload reductions were accomplished using balloon occlusion of the inferior vena cava. Preload recruitable stroke work (PRSW) was calculated using both intracavitary left ventricular pressure (LVPic) and LVPtm, and differences were tested for using a paired t-test.

RESULTS

The pericardial and pleural interventions produced significant elevations in ECP. No difference in PRSW calculated using LVPic and LVPtm was detected.

CONCLUSION

These results suggest that LVPtm need not be measured and included in LVPVR analysis of systolic function when there is significant external cardiac pressure. To be able to employ LVPVR analysis of systolic function without reference to LVPtm is important for simplified application in the clinical setting, particularly when elevated extracardiac pressures are suspected, or have been therapeutically induced, as with continuous positive pressure ventilation.

Delayed diagnosis of cardiac tamponade following isolated blunt abdominal trauma

Traumatic haemopericardium is an uncommon but life threatening condition. It is usually caused by penetrating cardiac injuries or cardiac rupture from blunt chest trauma. We report haemopericardium and cardiac tamponade in a young girl after blunt abdominal trauma. She presented with mild upper abdominal pain, tachycardia and hypotension having been kicked in the abdomen by a horse. No damage was found at laparotomy and she remained haemodynamically unstable. Further investigation found cardiac tamponade and haemopericardium. This was managed by insertion of a pericardial drain using transthoracic echocardiogram guidance, with later drainage in the operating theatre using guidance with a transoesophageal echocardiogram.

Diastolic heart failure. Constrictive, restrictive, and pericardial

Clinical heart failure with normal systolic function is suggestive of diastolic dysfunction. This can result from myocardial or pericardial disorders. Myocardial disorders are a broad range of pathologies leading to restrictive physiology. Amyloidosis is a prototype of restrictive cardiomyopathy leading to diastolic dysfunction. Pericardial disorders leading to diastolic heart failure are usually in the form of constrictive physiology. Differentiation between restrictive and constrictive pathologies is often difficult and require careful attention to hemodynamic and Doppler echocardiographic features.

Large Pericardial Effusions

Pericardial effusions accompany a number of clinical conditions. The challenges facing the clinician when dealing with a pericardial effusion include assessing the urgency of draining the effusion, choosing the right approach for drainage, determining the mechanics of the effusion, and establishing a cause for the effusion. Currently available diagnostic methods, echocardiographic modalities in particular, greatly aid in the diagnostic assessment as well as in carrying out appropriate therapeutic strategies.

Cardiac tamponade after removal of atrial intracardiac monitoring catheters in a pediatric patient: case report

The incidence of cardiac tamponade after cardiac surgery is reported as ranging from 0.04% to 7%. Although a relatively infrequent complication, tamponade is associated with significant morbidity and mortality. Reports of tamponade after pediatric cardiac surgery are few and generally associated with postcardiotomy syndrome or, less commonly, removal of left atrial or pulmonary artery catheters after surgery. A case is presented of cardiac tamponade in a pediatric patient resulting from removal of a direct atrial and a pulmonary artery catheter after cardiac surgery. The pathophysiology of cardiac tamponade is reviewed and the increased risk for pediatric patients is outlined. The case review is conducted in the context of existing policies in the reporting institution and recommendations for practice are discussed.

Relationship between pericardial pressure and lymphatic pericardial fluid transport in sheep

We investigated the relationship between pericardial pressure and the volumetric lymphatic clearance rate of pericardial fluid in sheep. A single catheter perfusion system was established to deliver tracer to the pericardial cavity and control pericardial pressure. In addition, catheters were placed into the thoracic duct and into the jugular vein at the base of the neck. (125)I-human serum albumin (HSA) was administered into the pericardial perfusate to serve as the lymph flow marker and its concentration monitored in the effluent from the outflow end of the perfusion system. (131)I-HSA was injected intravenously to permit calculation of plasma tracer loss and tracer recirculation into lymphatics. From mass balance equations, estimates of total pericardial clearance into lymphatics increased significantly as pericardial pressures were elevated in 2. 5 cm H(2)O increments from 2.5 to 12.5 cm H(2)O (P = 0.018). Pericardial lymph transport ranged from 0.89 +/- 0.10 to 3.09 +/- 0. 66 ml/h at 2.5 and 12.5 cm H(2)O pericardial pressure, respectively. The majority of transport occurred through mediastinal vessels with a small proportion (10.3 to 23.9%) being cleared into lymphatics leading to the thoracic duct. We conclude that lymphatic pericardial fluid transport increases approximately 3.5-fold over a pericardial pressure range that encompasses the transition between the shallow and steep portions of the pericardial pressure-volume relationship.

Cardiac tamponade

OBJECTIVES

To review the oncologic emergency of cardiac tamponade through a case study presentation/analysis and a discussion of the pathophysiology, diagnosis, treatment, and nursing management.

DATA SOURCES

Research studies, review articles, book chapters, abstracts, and clinical practice.

CONCLUSIONS

Cardiac tamponade is a potentially life-threatening condition that is not uncommon in the oncology setting. It can result directly from the malignant or metastatic process or from the treatment of the malignancy. Observation and prompt intervention are mandatory to deal effectively with cardiac tamponade.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses play important roles in identifying patients at risk for cardiac tamponade and in recognizing signs and symptoms of cardiac tamponade early so this life-threatening emergency can be treated promptly.

Pericardial Effusion and Tamponade

Pericardial effusion may occur as a result of a variety of clinical conditions, including viral, bacterial, or fungal infections and inflammatory, postinflammatory, autoreactive, and neoplastic processes. More common causes of pericardial effusion and tamponade include malignancy, renal failure, viral and bacterial infectious processes, radiation, aortic dissection, and hypothyroidism. It can also occur after trauma or acute myocardial infarction (as in postpericardiotomy syndrome following cardiac or thoracic surgery) or as an idiopathic pericardial effusion. Although pericardial effusion is common in patients with connective tissue disease, cardiac tamponade is rare. Among medical patients, malignant disease is the most common cause of pericardial effusion with tamponade. Table 1 shows the causes of pericardial tamponade. The effusion fluid may be serous, suppurative, hemorrhagic, or serosanguineous. The pericardial fluid can be a transudate (typically occurring in patients with congestive heart failure) or an exudate. The latter type, which contains a high concentration of proteins and fibrin, can occur with any type of pericarditis, severe infections, or malignancy. Once the diagnosis of pericardial effusion has been made, it is important to determine whether the effusion is creating significant hemodynamic compromise. Asymptomatic patients without hemodynamic compromise, even with large pericardial effusions, do not need to be treated with pericardiocentesis unless there is a need for fluid analysis for diagnostic purposes (eg, in acute bacterial pericarditis, tuberculosis, and neoplasias). The diagnosis of pericardial effusion/tamponade relies on a strong clinical suspicion and is confirmed by echocardiography or other pericardial imaging modalities. Alternatively, when the diagnosis of cardiac tamponade is made, there is a need for emergency drainage of pericardial fluid by pericardiocentesis or surgery to relieve the hemodynamic compromise. Following pericardiocentesis, it is necessary to prevent recurrence of tamponade. Intrapericardial injection of sclerosing agents, surgical pericardiotomy, and percutaneous balloon pericardial window creation are techniques used to prevent reaccumulation of pericardial fluid and recurrence of cardiac tamponade.