Cardiac Tamponade

DEFINITION:

Cardiac Tamponade is a syndrome due to compression of the heart by the spill
pericardium, with a continuum in terms of severity ranking that can reach
a picture of severe low cardiac output and death.

PATHOPHYSIOLOGY:

In the cardiac tamponade as a result of increased intrapericardial pressure is
an increase and equalization of the diastolic P, with collapse of the cardiac cavities and
restriction of the flow of filling. As compensatory mechanisms will give a
hyperstimulation adrenergic system and RAAS (renin-angiotensin-aldosterone). The
clinical manifestations will occur as a result of low cardiac output and increased
peripheral vascular resistance (PVR).

ETIOLOGY (factors that predispose or precipitate tamponade)

• idiopathic or infectious pericarditis
• Sepsis
• Neoplasia (metastases: breast, lung, lymphoma, melanoma)
• Connective Tissue Diseases
• blunt trauma
• recent heart surgery
• aortic dissection
• Myocardial infarction (sd. postpericardiotomía, heart failure)
• Anticoagulant, thrombolytic
• catheters right cavities
• Renal failure
• Cyclosporine
• Hypothyroidism

DIAGNOSTIC

• Chest pain pericardíticas features may be absent, especially in
chronic.
• The clinic is determined by the low cardiac output:
• Shortness of breath and progressive effort initially to be at rest, with X-ray
no evidence of heart failure.
• Weakness, anorexia
• drowsiness, unconsciousness, syncope
• Sometimes debut with the complications: renal insufficiency (oligoanuria)
liver failure, mesenteric ischemia ...


 PHYSICAL EXAMINATION



The classic triad: hypotension, paradoxical pulse pressure + + engorgement jugular

• hypotension (sometimes shock situation.) If there is an answer
may be excessive hyperadrenergic normo / hypertension.
• Pulse paradoxus (drop in inspiratory TA> 10 mm Hg): AP> 10 mm Hg since
Korotkoff sounds are heard jerky (audible exhalation) until you hear
continuous. It also appears in other situations (tension pneumothorax, IAM DV, TEP,
asthma exacerbation ...)
• engorgement jugular venous pressure signs of elevated right IC data
• Oliguria (renal failure by low GC)
• Coldness and acral cyanosis (by the compensatory increase in PVR)
• Tachycardia (increased compensatory chronotropic low GC)
• Fever, especially if it is of infectious etiology (DD with septic shock!)
• Cardiac Auscultation: noises off, presence of pericardial rub (which may be
sometimes absent).

ECG & Investigations:

• nonspecific abnormalities: especially the chronic, although there may be alterations
ST-T of any stage of pericarditis.
• Almost pathognomonic: QRS electrical alternans
• Low voltage QRS. Tachycardia
• Electromechanical dissociation in critical situations

 IMAGING TECHNIQUES:  is important to emphasize that the patient's diagnosis
capping is clinical (evidence of low CG that engages the body) as a result
of a pericardial effusion (which is causing hemodynamic compromise) that
diagnosed by imaging techniques.

• Rx-ray: Cardiomegaly (if> 250 ml) with figure-shaped bottle. "
• transthoracic (required):
• significant pericardial effusion
• Collapse of cavities (mainly right)
• exaggerated respiratory flow variation AV (ET: 40%, Emi: 25-30%) and hepatic veins
("Breast and" abolished or reversed in expiration).
• Inferior vena cava dilated with abolition of collapse
• Transesophageal Echocardiogram: useful on occasion (loculated effusions
in the immediate postoperative period, identifying metastases, blood clots ...)
• RM-CT chest: little used.

DIFFERENTIAL DIAGNOSIS:

• Other causes of the classic triad (hypotension, jugular venous distension and pulsus paradoxus)
PTE, tension pneumothorax, myocardial infarction VD ...
• With other causes of low cardiac output or conditions of shock: septic shock,
postoperative hemorrhagic shock in recent ...

EMERGENCY therapeutic approach
Tamponade is a critical situation that requires urgent and aggressive treatment, is a
income situation always.
• pericardial drainage (ideally in a CCU / ICU): Needle pericardiocentesis
(Apical, subxiphoid), sometimes surgical drainage.
• To make the drain: leave BP with volume and inotropes, correct acidosis
metabolic O2 and avoid PEEP in intubated patients.
• If DEM: CPR and pop-up drain