Cardiac Tamponade - Medical and Surgical Care

Medical Care

Cardiac tamponade is a medical emergency. Preferably, patients should be monitored in an intensive care unit.

1. All patients should receive the following:

• Oxygen

• Volume expansion with blood, plasma, dextran, or isotonic sodium chloride solution, as necessary to maintain adequate intravascular volume

• Bed rest with leg elevation: This may help increase venous return.

• Inotropic drugs (eg, dobutamine): These can be useful because they do not increase systemic vascular resistance while increasing cardiac output.

• Positive-pressure mechanical ventilation: This should be avoided because it may decrease venous return.

2. Further medical care includes the following:

• Pericardiocentesis: Removal of pericardial fluid is the definitive therapy for tamponade.

• Emergency subxiphoid percutaneous drainage: This is a life-saving bedside procedure. The subxiphoid approach is extrapleural; hence, it is the safest for blind pericardiocentesis. A 16- or 18-gauge needle is inserted at an angle of 30-45° to the skin, near the left xiphocostal angle, aiming towards the left shoulder. When performed emergently, this procedure is associated with a reported mortality rate of approximately 4% and a complication rate of 17%.

• Echocardiographically guided pericardiocentesis (often performed in the cardiac catheterization laboratory): This is usually performed from the left intercostal space. First, mark the site of entry based on the area of maximal fluid accumulation closest to the transducer. Then, measure the distance from the skin to the pericardial space. The angle of the transducer should be the trajectory of the needle during the procedure. Avoid the inferior rib margin while advancing the needle to prevent neurovascular injury. Leave a 16-gauge catheter in place for continuous drainage.

• Percutaneous balloon pericardiotomy: This can be performed using an approach similar to that for echo-guided pericardiocentesis, in which the balloon is used to create a pericardial window.

• Treatment of the underlying cause to prevent recurrence

3. Drug :

Dobutamine (Dobutrex) -- Synthetic catecholamine and a direct inotropic agent that stimulates cardiac beta-receptors with minimal increase in systemic vascular resistance.

Surgical Care: For a hemodynamically unstable patient or one with recurrent tamponade, provide the following care:

2. Surgical creation of a pericardial window: This involves the surgical opening of a communication between the pericardial space and the intrapleural space. Open thoracotomy and/or pericardiotomy may be required in some cases, and these should be performed by an experienced surgeon.

3. Pericardiodesis or sclerosing the pericardium: This is a therapeutic option for patients with recurrent pericardial effusion or tamponade. Through the intrapericardial catheter, corticosteroids, tetracycline, or antineoplastic drugs (eg, anthracyclines, bleomycin) can be instilled into the pericardial space.

4. Pericardio-peritoneal shunt: In some patients with malignant pericardial effusions, creation of a pericardio-peritoneal shunt helps prevent recurrent tamponade.

5. Pericardiectomy: Resection of the pericardium (pericardiectomy) through a median sternotomy or left thoracotomy is rarely required to prevent recurrent pericardial effusion and tamponade.

Category: Medicine Notes