10/13/2018

Cardiac
Tamponade

Supervised By

Dr / Farag Abd El-Wahab

 Made By:

Ola Maher Murad El-Saed

Shaimaa Gamal Mahfouz
Nada Mohamed Ahmed Hammad
Amira Khalid Ebrahim
Dina Fayez Mohamed
Reham Ali Abo El-Nour
Eman Essam El-Shafie
INTRODUCTION
The normal pericardium is a fibroblastic sac containing a thin layer of fluid that
surrounds the heart

. pericardium is a double-walled sac containing the heart and the roots of the great
vessels. The pericardial sac has two layers, a serous layer and a fibrous layer. It
encloses the pericardial cavity which contains pericardial fluid.

The pericardium fixes the heart to the mediastinum, gives protection against infection and
provides the lubrication for the heart

The pericardium is a tough double layered fibroserous sac which covers the heart. There
are two layers to the pericardial sac: the outermost fibrous pericardium and the inner
serous pericardium.

Fibrous pericardium
The fibrous pericardium is the most superficial layer of the pericardium. It is made up
of dense and loose connective tissue, which acts to protect the heart,

Serous pericardium
The serous pericardium, in turn, is divided into two layers, the parietal pericardium, which
is fused to and inseparable from the fibrous pericardium, and the visceral pericardium,

 In between the parietal and visceral pericardial layers there is a potential

space called the pericardial cavity, which contains a supply of lubricating serous
fluid known as the pericardial fluid. Normal levels of pericardial fluid are from 15
to 50 mL

 When the large amounts of fluid accumulate (pericardial effusion) or when the
pericardium becomes scarred and inelastic, one of three pericardial compressive
syndromes may occur:

 Pericardial effusion ("fluid around the heart") is an abnormal accumulation of

fluid in the pericardial cavity. Because of the limited amount of space in the
pericardial cavity, fluid accumulation leads to an increased intrapericardial
pressure which can negatively affect heartfunction. A pericardial effusion with
enough pressure to adversely affect heart function is called cardiac tamponade.
Pericardial effusion usually results from a disturbed equilibrium between the
production and re-absorption of pericardial fluid, or from a structural abnormality
that allows fluid to enter the pericardial cavity.

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Definition
Cardiac tamponade is a medical emergency.
Cardiac tamponade is the accumulation of pericardial fluid, blood, pus, or air
within the pericardial space that creates an increase in intrapericardial
pressure, restricting cardiac filling and decreasing cardiac output. Cardiac
tamponade can be fatal if it is not quickly diagnosed and treated
promptly. The diagnosis is based on clinical suspicion and supported by
evidence of hemodynamic compromise on echocardiography.

Epidemiology
The frequency of tamponade is unclear. One estimate from the United States places it at
2 per 10,000 per year. It is estimated to occur in 2% of those with stab or gunshot
wounds to the chest.

Pathophysiology
 The outer layer of the heart is made of fibrous tissue which does not easily
stretch, so once fluid begins to enter the pericardial space, pressure starts to
increase.
 If fluid continues to accumulate, each successive diastolic period leads to less
blood entering the ventricles. Eventually, increasing pressure on the heart forces

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 the septum to bend in towards the left Pathophysiolo Pathophysiology gy
ventricle, leading to a decrease instroke volume. This causes the development
of obstructive shock, which if left untreated may lead to cardiac arrest (often

presenting as pulseless electrical activity).

Causes:

The causes of pericardial penetration or fluid accumulation might include:

 gunshot or stab wounds

 blunt trauma to the chest from a car or industrial accident

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accidental perforation after cardiac catheterization, angiography, or insertion of a

pacemaker

 punctures made during placement of a central line, which is a type of catheter that
administers fluids or medications

 cancer that has spread to the pericardial sac, such as breast or lung cancer

 a ruptured aortic aneurysm

 pericarditis, an inflammation of the pericardium

 lupus, an inflammatory disease in which the immune system mistakenly attacks

healthy tissues

 high levels of radiation to the chest

 hypothyroidism, which increases the risk for heart disease

 a heart attack

 kidney failure

 infections that affect the heart

Risk factors
 malignancy
 aortic dissection
 purulent pericarditis
 large idiopathic pericardial effusion

Clinical picture:

Cardiac tamponade has the following symptoms:

 anxiety and restlessness

 low blood pressure

 weakness

 chest pain radiating to your neck, shoulders, or back

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  trouble breathing or taking deep breaths

 rapid breathing

 discomfort that’s relieved by sitting or leaning forward

 fainting, dizziness, and loss of consciousness

 abdominal pain

 confusion

 fever

Diagnosis:

Cardiac tamponade often has three signs can be recognized. These signs are
commonly known as Beck’s triad. They include:

 low blood pressure and weak pulse because the volume of blood your heart is
pumping is reduced
 extended neck veins because they’re having a hard time returning blood to
your heart
 a rapid heartbeat combined with muffled heart sounds due to the expanding
layer of fluid inside your pericardium

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Other diagnostic tests may include:
 a thoracic CT scan to look for fluid accumulation in the chest or changes to
the heart
 a magnetic resonance angiogram to see how blood is flowing through your
heart

 an electrocardiogram to assess your heartbeat

An ultrasound of the heart showing cardiac tamponade.[12]

 x ray


 ECG

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 

Differentials
o Constrictive pericarditis
o Restrictive cardiomyopathy

Cardiogenic shock
 ●Constrictive pericarditis – Constrictive pericarditis is the result of scarring and
consequent loss of elasticity of the pericardial sac. Pericardial constriction is
typically chronic, but variants include subacute, transient, and occult constriction.

 ●Effusive-constrictive pericarditis – Effusive-constrictive pericarditis is

characterized by underlying constrictive physiology with a coexisting pericardial
effusion, usually with cardiac tamponade. Such patients may be mistakenly
thought to have only cardiac tamponade; however, elevation of the right atrial and
pulmonary wedge pressures after drainage of the pericardial fluid points to the
underlying constrictive process.

 In both cardiac tamponade and constrictive pericarditis, cardiac filling is impeded

by an external force. The normal pericardium can stretch to accommodate
physiologic changes in cardiac volume. However, after its reserve volume is
exceeded, the pericardium markedly stiffens. An important pathophysiologic

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 feature of both cardiac tamponade and constrictive pericarditis is greatly
enhanced ventricular interaction or interdependence, in which the hemodynamics
of the left and right heart chambers are directly influenced by each other to a
much greater degree than normal.

Treatment:
Hospital management

Initial management in hospital is by pericardiocentesis. This involves the insertion of a

needle through the skin and into the pericardium and aspirating fluid under ultrasound
guidance preferably. This can be done laterally through the intercostal spaces, usually
the fifth, or as a subxiphoid approach.[15][16] A left parasternal approach begins 3 to 5 cm
left of the sternum to avoid the left internal mammary artery, in the 5th intercostal
space.[17] Often, a cannula is left in place during resuscitation following initial drainage so
that the procedure can be performed again if the need arises. If facilities are available, an
emergency pericardial window may be performed instead,[8] during which the pericardium
is cut open to allow fluid to drain. Following stabilization of the patient, surgery is
provided to seal the source of the bleed and mend the pericardium.
In people following heart surgery the nurses monitor the amount of chest tube drainage.
If the drainage volume drops off, and the blood pressure goes down, this can suggest
tamponade due to chest tube clogging. In that case, the patient is taken back to the
operating room for an emergency reoperation.
If aggressive treatment is offered immediately and no complications arise (shock, AMI or
arrhythmia, heart failure, aneurysm, carditis, embolism, or rupture), or they are dealt with
quickly and fully contained, then adequate survival is still a distinct possibility.

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 References
1. Spodick, DH (Aug 14, 2003). "Acute cardiac tamponade". The New England Journal
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2. : Richardson, L (November 2014). "Cardiac tamponade". JAAPA : Official Journal of
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9. Isselbacher EM, Cigarroa JE, Eagle KA (Nov 1994). "Cardiac tamponade
complicating proximal (retrograde) aortic dissection. Is pericardiocentesis
harmful?".Circulation. 90 (5): 2375–8.doi:10.1161/01.CIR.90.5.2375. PMID 7955196.