Pericardial tamponade

Theory

This is an emergency situation requiring immediate assessment and management.

Management focuses on urgent decompression of the pericardial cavity. Failure to do this leads to rising intra-cardiac pressure, reduced diastolic ventricular filling, decreased cardiac output, and ultimately cardiac arrest.

Immediate intern management

Attend patient and make rapid assessment.

If patient unconscious/arrest

Tell nursing staff to call Code Blue then move to head end of bed.
Perform triple manoeuvre – chin lift, jaw thrust, head tilt.
Clear mouth – suction secretions.
Insert Guedel airway and bag and mask.
Check pulse and if arrested start CPR.

If conscious/profoundly hypotensive/help arrives

Assess patient – continous pulse oximetry, vital signs

Tachycardia, hypotension
Raised JVP/ distended neck veins } = Pericardial tamponade
Muffled/ absent heart sounds

Pericardial tamponade (If patient unstable and deteriorating – usually this would be done by senior staff after echo confirmatory evidence)

Call Code Blue.
Organise for needle pericardiocentesis:
- Obtain the longest and largest IV needle available.
- Obtain sterile set up.

Obtain crash trolley.
Obtain IV access and IV fluid resuscitate.
Nil orally.

By now help should have arrived. Proceed to definitive management.

Clinical features (obtain rapidly)

History

Basic information about patient
Recent AMI/underlying medical problems

Examination

Pt in extremis
Hypotension, tachycardia
Raised JVP (central venous hypertension)
Muffled heart sounds

Other signs

Absent apex beat
Kussmaul’s sign (JVP rising with inspiration)

Causes

Post transmural AMI and ventricle rupture
Trauma
Thoracic aortic dissection
Cancer
Post-op cardiac surgery – notify the surgeon

Pericardiocentesis

Use sterile technique
Insert large bore needle (may need to use lumbar puncture needle) connected to syringe immediately inferior to xiphisternum directed towards left shoulder tip
Continuously aspirate from syringe
When in space, a rush of blood should indicate access to pericardial space
Improvement in BP should accompany successful decompression of the pericardial cavity

Investigations

CXR – enlarged heart
ECG – low voltage QRS throughout
Echocardiogram

Further definitive management

There may be time to establish the diagnosis with an echocardiogram prior to needle pericardiocentesis. This decision should be made by more senior staff
Pericardiocentesis performed as described previously
Definitive management requires exploratory thoracotomy/sternotomy to identify and control the cause of bleeding
This may include creation of a pericardial window to definitively drain a pericardial effusion. This can be done using a variety of approaches (subxiphoid, transcostal, or via thoracoscopic approaches)
These procedures should be done in theatre

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