Cardiac tamponade
Cardiac tamponade is the accumulation of fluid in the pericardial cavity, causing restriction of ventricular and atrial filling, systemic venous congestion, and decreased cardiac output.
Etiology
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- Uremia
- Neoplastic processes in the chest cavity, lungs, lymphoma, leukemia
- MI (heart rupture, Dressmr’s syndrome)
- In the postoperative period – up to 30% after pericardiotomy
- Viral infections – coxsackie group B, influenza, ECHO, herpes
- Bacterial infections – S. aureus, M. tuberculosis, Streptococcus pneumoniae (not common)
- Fungal infections – M. capsulatum
- SLE and rheumatoid diseases
- Trauma
- Insertion of a central venous catheter
- Myxedema
- » Taking certain drugs (anticoagulants, procainamide, minoxidil, isoniazid, hydralazine, cromolyn). Risk factors
- Cardiac tamponade should be suspected in patients with hemodynamic instability
- IM
- Pericarditis
- Blunt or penetrating chest injury
- Open heart surgery or catheterization
- In the presence (or suspicion) of a neoplastic process in the chest cavity
- Suspicion of a dissecting aortic aneurysm
- Kidney failure or dialysis. Pathogenesis
- The accumulation of fluid in the pericardium causes a rise in diastolic pressure in the ventricles, the ability to contract is saved until the increase in diastolic pressure
will not lead to a violation of coronary perfusion, which occurs with an increase in CVP to 350-400 mm of water.
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- With a very rapid accumulation of fluid in the pericardial cavity or with a rupture of the heart, circulatory arrest occurs due to reflex disorders before an increase in CVP, before 150-300 ml of exudate enters the pericardium
- Decreased filling of the heart leads to a decrease in cardiac output
- External pressure from the fluid in the pericardium is evenly transmitted to all four chambers of the heart. Since the external pressure is traditionally higher than the normal filling pressure, the pressure inside the pericardium, in the right and left ventricles and atria is equalized in diastole.
- Compensatory mechanisms in cardiac tamponade – increased peripheral resistance, increased CVP and tachycardia
- In patients with increased diastolic pressure in the left ventricle (as in chronic arterial hypertension), the resistance to filling the left ventricle remains constant. During the entire cardiac cycle, equalization of pressure in these patients is observed only in the right parts of the heart.
Clinical picture
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- The most common complaint is excruciating shortness of breath even with minimal exertion.
- In severe cases, the patient experiences fear of death, attacks of severe weakness appear with cold, sticky sweat, cyanosis, and a thready pulse. Fainting develops, which is an indication for an urgent puncture of the pericardium.
- Tachycardia is a compensatory mechanism to maintain cardiac output.
- Decreased systolic and pulse pressure.
- Paradoxical pulse – weakening or disappearance of the arterial pulse on inspiration, a drop in systolic blood pressure by more than 10 mm Hg. between inspiratory and expiratory phases.
- The jugular veins are swollen, with all this, a jugular phlebogram or a right atrial pressure recording curve reveals a rapid systolic decrease (wave X) and a weakening or absence of a diastolic decrease (phase Y).
- Soreness on palpation in the right hypochondrium due to stagnation of blood in the liver.
- Expansion of the zone of cardiac dullness beyond the apex beat.
Laboratory research
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- General blood test
- SOE
- Cardiac enzymes to rule out MI
- Antinuclear AT
- RF
- Blood urea nitrogen/creatinine
- Fluid from the pericardial cavity – for a culture of bacteria, fungi, mycobacteria, Thunder stain, Ht, cell number, cytology, glucose, protein, RF, complement level. Special Studies
- EKG
- Low voltage QRS complex
- Alternation of electrical activity (changes in the R wave from complex to complex)
- Alternation of electrical activity is observed in 10-20% of cases of tamponade (50-60% of them are of neoplastic origin).
- Right heart catheterization
- Equalization (within 2-3 mm) of pressure between the right atrium, pulmonary artery and capillary wedge pressure, as well as between pressure in the left atrium and end-diastolic pressure in the left ventricle
- Absence of diastolic decrease in Y on the atrial pressure recording curve.
- Chest x-ray: enlargement of the shadow of the heart (in the presence of more than 250 ml of fluid in the pericardial cavity). Differential Diagnosis
- Tension pneumothorax
- Acute right ventricular failure
- Chronic obstructive pulmonary disease
- Constrictive pericarditis
- THE BODY
- Fat embolism
- Excessive or accelerated fluid therapy
- Bloating due to ascites or bowel obstruction
- Increased intrathoracic pressure due to pneumothorax, hemothorax, airway obstruction.
Treatment: – stationary mode, bed. Tactics of conducting
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- Emergency pericardiocentesis
- To stabilize hemodynamics – infusion therapy, drugs with a positive inotropic effect
- Continuous monitoring until complete stabilization of the condition
- Every 15 minutes, blood pressure, heart rate, CVP, as well as the wedge pressure of the capillaries of the pulmonary artery are measured using a Swan-Ganz catheter.
Surgical treatment is pericardiocentesis (see Effusive Pericarditis).
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- Indications
- Rapid hemodynamic disturbance
- Delayed surgery due to traumatic blood loss
- diagnostic goals.
- Blind pericardial puncture is performed in an emergency, life-threatening.
- The passage of the needle and the removal of fluid will need to be carried out under echocardiographic control (fluoroscopy is also used).
- Unwanted contact with the epicardium is monitored using a chest ECG electrode attached to a trocar or needle.
- If a rapid re-accumulation of fluid in the pericardial cavity is expected (for example, with neoplastic formations), it is possible to install a drainage tube for a long period or the introduction of sclerosing agents.
- Emergency surgical intervention for vital indications in case of hemotamponade in case of heart rupture.
- Invasive monitoring to control the magnitude of pressure in the pericardial cavity.
Complications – see Effusive pericarditis.