Important Things to Know About Pericardial Tamponade

As a current or future health care professional, your ability to quickly recognize symptoms of cardiac problems can mean the difference between life or death for your patients. Because the heart is responsible for circulating oxygen‐rich blood throughout the body, emergency conditions affecting this organ can very rapidly lead to serious and sometimes fatal complications.

One example of a medical emergency involving the heart is a condition called pericardial tamponade (also called cardiac tamponade). Keep reading to learn more about pericardial tamponade, including what it is, what causes it, what the main signs and symptoms are, and how it is diagnosed and treated.

What is Pericardial Tamponade?

Pericardial tamponade is a medical condition caused by blood or fluids filling the space between the heart muscle and the sac (called the pericardium or pericardial sac) surrounding the heart muscle. This abnormal fluid build-up causes an enormous amount of pressure on the heart, which prevents the heart muscle from being able to fully expand and beat properly. As a result, the heart can’t fill up with as much blood as it normally does.

When the heart can’t fill up with enough blood, it won’t be able to pump enough blood out to the body. The brain and other organs will become starved of oxygen, and organ failure can occur relatively quickly. Other serious complications of cardiac tamponade include anoxic brain injury, coma, and shock. Without treatment, pericardial tamponade is fatal.

Pericardial Tamponade and Pericardial Effusion: What’s the Difference?

Pericardial effusion and tamponade are related but distinct conditions affecting the heart. Pericardial effusion is the term medical professionals use for the actual process of the pericardial sac filling up with fluid. Cardiac tamponade—in which excessive pressure from the fluid surrounding the heart prevents the heart from beating properly—is a condition that can result from pericardial effusion.

Pericardial effusions that develop slowly don’t always lead to cardiac tamponade, because the pericardial sac will have more time to stretch in response to the fluid build-up (therefore avoiding excessive pressure on the heart muscle). Cardiac tamponade often develops when the fluid build-up develops suddenly and quickly. However, cardiac tamponade can develop slowly in some cases—over days, weeks, or even months.

What Causes Pericardial Tamponade?

Pericardial tamponade can be caused by illness or injury, whether acute or chronic. It’s commonly caused by trauma or injury to the pericardial sac (e.g., foreign object penetration), which allows fluids and blood to flow inside the sac and around the heart.

Some specific causes of pericardial effusion and subsequent pericardial tamponade include:

• Gunshot wounds or stab wounds to the chest and heart
• Blunt trauma to the chest (e.g., from a car accident, work-related accident, slip, fall, etc.)
• Complications during cardiac procedures, including catheterization, angiography, insertion of a pacemaker or central line, or any other type of heart surgery or chest surgery
• A ruptured aortic aneurysm (a balloon-like bulge in the aorta)
• An aortic dissection (a tear in the inner layer of the aorta—according to the European Cardiac Society, tamponade is a leading cause of death in patients with acute aortic dissections)
• Cancers, including leukemia and end-stage lung cancer or breast cancer that have spread to the pericardium
• Myocardial infarction (heart attack)
• Sudden cardiac arrest
• High levels of radiation exposure to the chest area
• Kidney failure and end-stage kidney disease
• Congestive heart failure (when the heart doesn’t pump blood as well as it should)
• Infections that affect the blood, heart, or pericardial sac (e.g., pericarditis caused by bacterial or viral infections, as well as tuberculosis and HIV/AIDS)
• Lupus, a chronic autoimmune disease that causes a person’s immune system to mistakenly attack healthy tissues in their body, including the heart and pericardium
• Hypothyroidism, also called underactive thyroid, in which the thyroid gland doesn’t produce enough hormones (hypothyroidism is considered a risk factor for heart disease, including heart failure)
• Dermatomyositis is a rare autoimmune condition that causes inflammation and weakness of the muscles and skin

Did you know?

According to a 2014 study published in Circulation: Arrhythmia and Electrophysiology, cardiac tamponade is the leading cause of procedure-related mortality among patients undergoing catheter ablation. Catheter ablation is a common procedure used to treat a heart condition called atrial fibrillation (AF), in which the heart beats fast and irregularly and the heart’s upper chambers (atria) do not beat in time with the heart’s lower chambers (ventricles).

This same study—which looked at data from nearly 35,000 catheter ablation procedures—found that tamponade during ablations is rare, affecting about 1.2 to 1.3 percent of people undergoing this procedure. However, women undergoing ablations for AF are about twice as likely to experience tamponade than men.

Recognizing Pericardial Tamponade in Patients: Signs and Symptoms

A person experiencing cardiac tamponade will exhibit at least one and usually several of the following signs and symptoms:

• Anxiety or restlessness
• Confusion
• Weakness
• Low blood pressure (hypotension)
• Chest pain that radiates to the neck, shoulders, and/or back
• Chest pain that gets worse with coughing or deep breathing
• Chest pain that improves by sitting or leaning forward
• Respiratory distress or trouble breathing
• Rapid breathing
• Weak or thready pulse, especially in the arms or legs
• Heart palpitations (feeling like the heart is pounding, racing, or skipping beats)
• Pale, blue, and/or clammy skin
• Swelling in the arms or legs
• Dizziness
• Fainting (syncope) or loss of consciousness

Diagnosing and Treating Patients With Pericardial Tamponade: What to Expect

Do you know the three clinical signs of cardiac tamponade that doctors use to help diagnose this emergency condition? Known as “Beck’s triad,” these signs include:

• Low blood pressure: because the heart is not able to pump as much blood as it usually does
• Distention (bulging) of the jugular veins located in the neck: because blood from the veins is unable to flow into the heart easily
• Muffled heart sounds are heard while listening to the heart with a stethoscope: because the pressure from fluid inside the pericardial sac blocks the sound of the heart

Doctors don’t rely only on clinical signs to determine if a person has pericardial tamponade. They’ll also order tests to help confirm a diagnosis and rule out other conditions.

The primary test doctors use to diagnose this condition is an echocardiogram (ultrasound of the heart). If a person experiencing cardiac tamponade undergoes an echocardiogram, the echocardiogram might reveal a distended (enlarged) pericardium or collapsed ventricles inside the heart, which happens due to low blood volume inside the ventricles.

Additional tests and imaging studies doctors might order to diagnose cardiac tamponade include:

• Chest X-ray, to assess the size and shape of the heart
• Thoracic CT scan, to look for changes to the heart and fluid accumulation in the chest area
• Magnetic resonance angiogram, to assess how blood flows through the heart
• Electrocardiogram (ECG), to assess the way the heartbeats

Treatment of Pericardial Tamponade

Remember: pericardial tamponade is a life-threatening, emergency situation that requires immediate medical treatment. The primary aim of treatment is to remove the excess fluids from inside the pericardium, which should help reduce pressure on the heart. This can be done with an emergency procedure known as pericardiocentesis, in which a doctor—guided by imaging technology like an echocardiogram or X‑ray fluoroscopy—inserts a large needle into the chest and through the pericardium. The doctor can then remove fluid through this needle.

Other invasive surgical procedures might be required to help remove damaged tissue and repair damaged areas. This is often necessary when cardiac tamponade is caused by an acute injury and pericardiocentesis is not possible. In the most severe cases, doctors might need to perform an emergency procedure known as a thoracotomy, which opens the chest so the medical team can see and gain direct access to the heart area.

People recovering from cardiac tamponade may also require additional treatments and medication, such as pain relievers or antibiotics. If other complications or disease states are present (e.g., autoimmune diseases, other orthopedic or neurological injuries caused by physical trauma), the patient’s medical team should be prepared to manage these issues, too.

Outcomes for People with Pericardial Tamponade

According to the U.S. National Library of Medicine, an estimated two out of every 10,000 people are affected by cardiac tamponade caused by an underlying disease (not including trauma). However, the overall incidence and prevalence of this condition is unknown.

Pericardial tamponade is difficult to predict and prevent, but early detection and treatment can improve a patient’s outcomes. Generally speaking, patients who have cardiac tamponade that develops slowly over time tend to fare better than patients who have cardiac tamponade that develops suddenly.

Caring for a Patient with Pericardial Tamponade: Things Every Health Care Provider Should Know

• Pericardial tamponade is a serious health emergency that requires immediate medical attention. It is always fatal if not treated.
  This condition can present like other health problems, including cardiogenic or obstructive shock. People with cardiac tamponade may be in pulseless electrical activity (PEA) cardiac arrest by the time they reach the hospital.
• In addition to Beck’s triad (hypotension, muffled heart sounds, and distended jugular veins), people with cardiac tamponade might exhibit “pulses paradoxus,” in which systolic blood pressure decreases by more than 10 mmHg with inspiration.
• Health care workers providing direct care for patients with cardiac tamponade can expect to implement a range of interventions, including medications, stat imaging, and bloodwork, ECG monitoring, strict bed rest with legs elevated, supplemental oxygen, and large-bore IVs. Having fluids available and a pericardiocentesis tray standing by can improve the delivery and speed of care if the patient’s condition deteriorates rapidly.
• Following emergency treatment, catheters are often left in the pericardial sac to encourage additional fluid draining. Health care personnel must be aware of not only how to properly care for these drains but to monitor their output and relay this information to the doctor.

Outside the emergency room, the intensive care unit (ICU) is the most appropriate place for patients with newly diagnosed cardiac tamponade to be monitored and cared for by their medical team. The immediate post-treatment window is a critical time to ensure that the pericardial sac is not refilling with fluids.

Once a patient is medically stable enough to be taken out of this critical window, they may require comprehensive, multidisciplinary care from the medical team, including physical therapy, occupational therapy, and cardiac rehabilitation, in order to safely advance their functional progress and recovery.

In Conclusion

Pericardial tamponade (or cardiac tamponade) is a life-threatening medical emergency caused by excess fluid build-up around the heart. Excess fluid puts increased pressure on the heart, preventing it from being able to fill with blood and pump out blood to the rest of the body. Patients who do not receive treatment for pericardial tamponade will die.

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