Cardiac Tamponade and Manage It Appropriately CREDIT WILLIAM A

Home , Korotkoff sounds, Pulsus paradoxus

REVIEW CME EDUCATIONAL OBJECTIVE: Readers will recognize the signs of cardiac tamponade and manage it appropriately CREDIT WILLIAM A. SCHIAVONE, DO, FACC Department of Cardiovascular Medicine, Cleveland Clinic

Cardiac tamponade: 12 pearls in diagnosis and management

■■ ABSTRACT ardiac tamponade is a life-threatening C condition that can be palliated or cured, Cardiac tamponade shares symptoms and signs such as depending on its cause and on the timeliness dyspnea, edema, and low urine output with other, more- of treatment. Making a timely diagnosis and common diseases. Consider it when there is chest trauma providing the appropriate treatment can be or when the patient has a chronic medical illness that can gratifying for both patient and physician. involve the pericardium. Successfully treating it can be Cardiac tamponade occurs when fluid in the pericardial space reaches a pressure ex- rewarding for both the patient and the physician. ceeding central venous pressure. This leads ■■ KEY POINTS to jugular venous distention, visceral organ engorgement, edema, and elevated pulmonary Slow accumulation of pericardial fluid can result in ede- venous pressure that causes dyspnea. Despite ma, whereas rapid accumulation leads to hypotension. compensatory tachycardia, the decrease in cardiac filling leads to a fall in cardiac output and to arterial hypoperfusion of vital organs. Diuretics can worsen tamponade by removing enough volume from the circulation to lower the central venous pressure below the intrapericardial pressure. ■■ PEARL 1: SLOW ACCUMULATION LEADS TO EDEMA

Try to determine why cardiac tamponade has occurred. The rate at which pericardial fluid accumu- Cardiac or aortic rupture requires surgery. If the gross lates influences the clinical presentation of appearance of the pericardial fluid does not match the cardiac tamponade, in particular whether or presumed etiology, reconsider your diagnosis. not there is edema. Whereas rapid accumulation is characterized more by hypotension Always review imaging studies before making the diag- than by edema, the slow accumulation of peri- nosis of cardiac tamponade. cardial fluid affords the patient time to drink enough liquid to keep the central venous pressure higher than the rising pericardial pressure. When cardiac tamponade is considered, pulsus para- Thus, edema and dyspnea are more prominent doxus must be measured, and if present, integrated with features of cardiac tamponade when there is a other physical findings and the echocardiogram. How- slow rise in pericardial pressure. ever, pulsus paradoxus can be present in the absence of cardiac tamponade, and vice versa. ■■ PEARL 2: EDEMA IS NOT ALWAYS TREATED WITH A DIURETIC Consider the size and location of the pericardial effusion and the patient’s hemodynamic status when deciding Edema is not always treated with a diuretic. In a patient who has a pericardial effusion that between surgery and needle aspiration. has developed slowly and who has been drink- doi:10.3949/ccjm.80a.12052 ing enough fluid to keep the central venous

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ing disease, but the focus is squarely on the effects of trauma or violent injury. In a patient with multiple trauma, hypotension and tachycardia that do not respond to intravenous volume replacement when there is an obvious rise in central venous pressure should be clues to cardiac tamponade.1 If the patient has recently undergone a cardiac procedure (for example, cardiac surgery, myocardial biopsy, coronary intervention, electrophysiologic study with intracardiac electrodes, transvenous pacemaker placement, pacemaker lead extraction, or radiofrequency ablation), knowing about the procedure narrows the differential diagnosis when hypotension, tachycardia, and jugular venous disten- FIGURE 1. Computed tomography of the chest in a 40-year- tion develop. old man who presented with a nagging cough 2 weeks after undergoing septal myectomy for hypertrophic obstruc- ■■ PEARL 4: CARDIAC OR AORTIC RUPTURE tive cardiomyopathy. The image shows a moderately large REQUIRES SURGERY pericardial effusion (arrows). The patient had a pulsus paradoxus of 15 mm Hg. Surgical pericardiostomy relieved When the etiology of cardiac tamponade is his cardiac tamponade and his cough. cardiac or aortic rupture, the treatment is surgical. pressure higher than the pericardial pressure, a Painful sudden causes of cardiac tampon- diuretic can remove enough volume from the ade include hemopericardium due to rupture circulation to lower the central venous pres- of the free wall after myocardial infarction, A recent sure below the intrapericardial pressure and and spontaneous or posttraumatic dissection cardiac thus convert a benign pericardial effusion to and rupture of the ascending aorta. Prompt potentially lethal cardiac tamponade. diagnosis is necessary, but since these lesions procedure One must understand the cause of edema will not close and heal spontaneously, the narrows the or low urine output before treating it. This definitive treatment should be surgery. More- differential underscores the importance of the history and over, needle removal of intrapericardial blood the physical examination. All of the following that has been opposing further bleeding is sure diagnosis when must be assessed: to permit bleeding to recur, often with lethal hypotension, • Symptoms and time course of the illness consequences.2 • Concurrent medical illnesses Causes of cardiac tamponade that have a tachycardia, • Neck veins less-acute onset are likely to be complications and jugular • Blood pressure and its response to inspira- of medical problems. Medical illnesses known tion to be associated with cardiac tamponade in- venous • Heart sounds clude: distention • Heart rate and rhythm • Infectious disease (idiopathic or viral, as- develop • Abdominal organ engorgement sociated with smallpox vaccination, myco- • Edema (or its absence). bacterial, purulent bacterial, fungal) • Metastatic cancer (lung, breast, esopha- ■■ PEARL 3: UNDERSTANDING THE CAUSE gus, lymphoma, pancreas, liver, leukemia, is essential stomach, melanoma)3 • Connective tissue disease (rheumatoid ar- Understanding the cause of cardiac tampon- thritis, systemic lupus erythematosus, an- ade is essential. kylosing spondylitis, scleroderma, Wegen- A trauma patient first encountered in the er granulomatosis, acute rheumatic fever) emergency department may have an underly- • Endocrine disease (hypothyroidism)

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• Drug side effects (procainamide, isoniazid, hydralazine, minoxidil, phenytoin, antico- agulants, methysergide) • Inflammatory bowel disease (Crohn disease, ulcerative colitis) • Congestive heart failure • Uremia • Radiation therapy • Postmyocardial infarction syndrome (Dressler syndrome) • Postpericardiotomy syndrome. IVC ■■ PEARL 5: REVIEW IMAGING BEFORE DIAGNOSING

What often brings a patient with cardiac tamponade to the attention of the physician is a finding on echocardiography, computed tomography, or magnetic resonance imaging of the chest. Always review the imaging studies before making the diagnosis of cardiac tamponade. These tests must be reviewed to assess the anatomy and the size and location of the effusion. Particularly, one must look for atrial and right ventricular collapse and inferior RV vena caval plethora, which are echocardio- 4 graphic signs of cardiac tamponade. FIGURES 1, 2, and 3 show imaging studies in a patient who presented with worsening cough 2 weeks after undergoing a cardiac procedure and who was found to have cardiac tamponade. When the history and these imaging studies place cardiac tamponade high in the differential diagnosis as the cause of edema or dyspnea, it is time to reexamine the patient. The best first step is to measure pulsus para- FIGURE 2. Top, an M-mode echocardiogram in the same pa- doxus. tient as in FIGURE 1 shows a plethoric inferior vena cava (IVC) over 12 heartbeats and 3 inspirations (arrows). Bottom, ■■ HOW PULSUS PARADOXUS OCCURS an M-mode echocardiogram of the left and right ventricles shows a large posterior pericardial effusion. Notice how the right ventricular chamber (RV) increases in size during To fully appreciate the subtleties of the next inspiration just before the third QRS complex (arrow). pearls, it is necessary to understand the patho- physiology of cardiac tamponade. When pericardial fluid accumulation raises racic pressure. During respiration, the right and the pericardial pressure above the central ve- left sides of the heart are alternately filled and nous pressure and pulmonary venous pressure deprived of their respective venous return. (intravascular pressure), blood will not pas- During inspiration, as the intrathoracic sively return to the right side of the heart from pressure decreases, blood in the venae cavae the venae cavae nor to the left side of the heart empties into the right side of the heart, while from the pulmonary veins unless it is influ- blood in the pulmonary veins preferentially enced by the effects of respiration on intratho- remains in the pulmonary veins, underfilling

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■■ PEARL 6: MEASURE PULSUS PARADOXUS

When cardiac tamponade is considered, one must always measure the pulsus paradoxus. The term pulsus paradoxus was coined by Adolph Kussmaul in 1873, before physicians could even measure blood pressure. All they could do at that time was palpate the pulse and listen to the heart. Kussmaul described his observation as a conspicuous discrepancy between the cardiac action and the arterial pulse. Although not described by Kussmaul, another explanation for this finding might be more suited to the use of the word “paradoxi- cal.” When the pulse is palpated in a normal patient, with inspiration the pulse rate will increase via the Bainbridge reflex, and with FIGURE 3. Pulsed-wave Doppler interrogation of mitral valve expiration it will decrease. But in a patient inflow during expiration (higher Doppler velocity and nadir with cardiac tamponade, there is a paradoxi- of respirometer green waveform) and inspiration (lower cal inspiratory slowing of the pulse (because Doppler velocity and peak of respirometer green waveform) the decreased magnitude of the pulse at times in the same patient as in FIGURE 1 and FIGURE 2. makes it imperceptible) and an expiratory increase in pulse rate as the magnitude of the the left side of the heart. Since the right ven- pulse again makes it palpable. tricle is more filled than the left ventricle dur- The magnitude of the fall in systolic blood ing inspiration, the ventricular septum shifts pressure during inspiration has been used to from right to left, further opposing pulmonary estimate the level of hemodynamic impair- Pulsus venous return. As a result, during cardiac tam- ment resulting from pericardial effusion.5 A paradoxus: ponade, the systemic blood pressure falls with rapidly accumulating pericardial effusion can inspiration. have more hemodynamic impact than a much An inspiratory During expiration the opposite occurs. Ex- larger one that accumulates slowly. Thus, the fall in systolic piration decreases the intrathoracic volume, intrapericardial pressure must be considered so the intrathoracic pressure rises. This tends more than the volume of pericardial fluid. blood pressure to oppose vena caval return to the right side When there is severe cardiac tamponade and > 10 mm Hg of the heart and to favor pulmonary venous overt pulsus paradoxus, simple palpation of a return to the left side of the heart. The ven- proximal arterial pulse can detect a marked inspi- tricular septum shifts from left to right, further ratory decrease or loss of the pulse, which returns accommodating left ventricular filling, raising with expiration. Tachycardia is almost always stroke volume, and increasing blood pressure. present, unless the cause is hypothyroidism.6 This exaggerated alternate filling of the right and left sides of the heart during cardiac tam- How to measure pulsus paradoxus ponade is what accounts for pulsus paradoxus, with a manual sphygmomanometer an inspiratory fall in systolic blood pressure of A stethoscope and manual sphygmomanom- greater than 10 mm Hg. eter are all that is needed to measure pulsus If intravascular pressure is low (due to hem- paradoxus. A noninvasive blood pressure orrhage, dehydration, or diuretic therapy), the monitor that averages multiple measurements pressure in the pericardial space needed to op- cannot detect or quantify pulsus paradoxus. pose venous return is much less. In this low- The patient should be supine with the pressure scenario, the results are low cardiac head elevated 30˚ to 45˚, and the examiner output and hypotension, which are treated by should be seated comfortably at the patient’s giving intravenous fluids to maintain intravas- side. The manometer should be on the op- cular volume. posite side of the patient in plain view of the

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FIGURE 4. Pulsus paradoxus can be detected using finger pulse oximeter plethysmography. Inspiration decreases the magnitude of the waveform with each QRS, and expiration increases its magnitude. Using this readily available tool, pulsus paradoxus that is caused by cardiac tamponade or severe lung disease can be detected. examiner. Position the cuff on the arm above this final value. This is the diastolic blood the elbow and place your stethoscope on the pressure. antecubital fossa. Then: • Inflate the cuff 20 mm Hg above the high- ■■ PEARL 7: THE PLETHYSMOGRAM WAVE- est systolic pressure previously auscultated. FORM PARALLELS PULSUS PARADOXUS • Slowly decrease the manometer pressure by 5 mm Hg and hold it there through two or Manual measurement of blood pressure and three respiratory cycles while listening for pulsus paradoxus can be difficult, especially the first Korotkoff (systolic) sound. Repeat in an obese patient or one with a fat-distorted this until you can hear the systolic sound arm on which the cuff does not maintain its (but only during expiration) and mentally position. In such patients, increased girth of note the pressure. the neck and abdomen also make it difficult • Continue to decrease the manometer pres- to assess the jugular venous distention and sure by 5-mm Hg increments while listening. visceral organ engorgement that characterize When the Korotkoff sounds no longer dis- cardiac tamponade. appear with inspiration, mentally note this When the use of a sphygmomanometer second value as well. The pulsus paradoxus is is not possible, an arterial catheter can be the difference between these values. inserted to demonstrate pulsus paradoxus. • When the Korotkoff sounds disappear as Simpler, however, is the novel use of another the manometer pressure is decreased, note noninvasive instrument to detect and coarsely

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quantify pulsus paradoxus.7 The waveform on is decreased. finger pulse oximetry can demonstrate pulsus Factors that can oppose pulsus paradoxus: paradoxus. The plethysmogram of the finger • Positive pressure ventilation prevents pul- pulse oximeter can demonstrate the decrease sus paradoxus by preventing the fall in in- in magnitude of the waveform with each intrathoracic pressure. spiration (FIGURE 4). • Severe aortic regurgitation does not permit Caution must be taken when interpreting underfilling of the left ventricle during in- this waveform, as with any measurement of spiration. pulsus paradoxus, to exclude a concomitant • An atrial septal defect will always equalize arrhythmia. the right and left atrial pressures, preventing differential right ventricular and left ■■ PEARL 8: PULSUS PARADOXUS ventricular filling with inspiration. WITHOUT CARDIAC TAMPONADE • Severe left ventricular hypertrophy does not permit the inspiratory shift of the Pulsus paradoxus can be present in the absence ventricular septum from right to left that of cardiac tamponade. Once pulsus paradoxus would otherwise lead to decreased left ven- of more than 10 mm Hg is measured, one must tricular filling. be sure the patient does not have a condition • Severe left ventricular dysfunction, with that can cause pulsus paradoxus without car- its low stroke volume and severe elevation diac tamponade. Most of these are pulmonary of left ventricular end-diastolic pressure, conditions that necessitate an exaggerated never permits underfilling of the left ven- inspiratory effort that can lower intrathoracic tricle, despite cardiac tamponade and an pressure sufficiently to oppose pulmonary ve- inspiratory decrease in intrathoracic pres- nous return and cause a fall in systemic blood sure. pressure: • Intravascular volume depletion due to • Chronic bronchitis hemorrhage, hemodialysis, or mistaken • Emphysema use of diuretics to treat edema can cause A stethoscope • Mucus plug marked hypotension, making pulsus para- and manual • Pneumothorax doxus impossible to detect. • Pulmonary embolism Knowledge of underlying medical condi- sphygmoma- • Stridor. tions, the likelihood of their causing cardiac nometer In these, there may be pulsus paradoxus, tamponade, and the appearance of the echo- are all that is but not due to cardiac tamponade. cardiogram prompt the physician to look further when the presence or absence of pulsus needed ■■ PEARL 9: CARDIAC TAMPONADE CAN BE paradoxus does not fit with the working diag- to measure PRESENT WITHOUT PULSUS PARADOXUS nosis. The echocardiogram can give hints to the pulsus Cardiac tamponade can be present without etiology of a pericardial effusion, such as clot- paradoxus pulsus paradoxus. This occurs when certain ted blood after trauma or a cardiac-perforating conditions prevent inspiratory underfilling of procedure, tumor studding of the epicardium,9 the left ventricle relative to the filling of the or fibrin strands indicating chronicity or an right ventricle.8 inflammatory process.10 Diastolic collapse of How does this work? In cardiac tampon- the right ventricle, more than collapse of the ade, factors that drive the exaggerated fall in right atrium or left atrium, speaks for the se- arterial pressure with inspiration (pulsus para- verity of cardiac tamponade. With hemody- doxus) are the augmented right ventricular namically significant pericardial effusion and filling and the decreased left ventricular fill- cardiac tamponade, the inferior vena cava is ing, both due to the lowering of the intratho- distended and does not decrease in size with racic pressure. As the vena caval emptying is inspiration unless there is severe intravascular augmented, the right ventricular filling is in- volume depletion, at which time the inferior creased, the ventricular septum shifts to the vena cava is underfilled throughout the respi- left, and pulmonary venous return to the heart ratory cycle.

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■■ PEARL 10: PLAN HOW TO DRAIN the basis of the presumed etiology, ie: Sanguinous—trauma, heart surgery, car- The size and location of the pericardial effu- diac perforation from a procedure, anticoagu- sion and the patient’s hemodynamics must be lation, uremia, or malignancy integrated when deciding how to relieve car- Serous—congestive heart failure, acute ra- diac tamponade. When cardiac tamponade is diation therapy indeed severe and the patient and physician Purulent—infections (natural or postop- agree that it must be drained, the options are erative) percutaneous needle aspiration (pericardiocen- Turbid (like gold paint)—mycobacterial tesis) and surgical pericardiostomy (creation of infection, rheumatoid arthritis, myxedema a pericardial window). Here again, as assessed Chylous—pericardium fistulized to the by echocardiography, the access to the pericar- thoracic duct by a natural or postsurgical cause. dial fluid should influence the choice. Sanguinous pericardial effusion encoun- Pericardiocentesis can be safely done if cer- tered during a pericardiocentesis, if not an- tain criteria are met. The patient must be able ticipated, can be daunting and can cause to lie still in the supine position, perhaps with the operator to question if it is the result of the head of the bed elevated 30 degrees. Anti- inadvertent needle placement in a cardiac coagulation must be reversed or allowed time chamber. If the needle is indeed in the heart, to resolve if drainage is not an emergency. blood often surges out under pressure in puls- Pericardiocentesis can be risky or unsuc- es, which strongly suggests that the needle cessful if there is not enough pericardial fluid is not in the pericardial space and should be to permit respiratory cardiac motion without removed; but if confirmation of the location perforating the heart with the needle; if the is needed before removing the needle, it can effusion is loculated (confined to a pocket) be done by injecting 2 mL of agitated sterile posteriorly; or if it is too far from the skin to saline through the pericardiocentesis needle permit precise control and placement of a spi- during echocardiographic imaging.12 nal needle into the pericardial space. In cases Before inserting the needle, the ideal ac- of cardiac tamponade in which the anatomy cess location and needle angle must be deter- Manual indicates surgical pericardiostomy but severe mined by the operator with echocardiographic measurement hypotension prevents the induction of an- transducer in hand. The distance from skin to esthesia and positive-pressure ventilation— a point just through the parietal pericardium of blood which can result in profound, irreversible can also be measured at this time. pressure hypotension—percutaneous needle drainage Once the needle is in the pericardial fluid and pulsus (pericardiocentesis) should be performed in (and you are confident of its placement), re- the operating room to relieve the tamponade moval of 50 to 100 mL of the fluid with a large paradoxus before the induction of anesthesia and the sur- syringe can be enough to afford the patient can be difficult, gical drainage.11 easier breathing, higher blood pressure, and To reiterate, a suspected cardiac or aortic lower pulsus paradoxus—and even the phy- especially in an rupture that causes cardiac tamponade is usu- sician will breathe easier. The same syringe obese patient ally large and not apt to self-seal. In such cas- can be filled and emptied multiple times. Less es, the halt in the accumulation of pericardial traumatic and more complete removal of peri- blood is due to hypotension and not due to cardial fluid requires insertion of a multihole spontaneous resolution. Open surgical drain- pigtail catheter over a J-tipped guidewire that age is required from the outset because an ini- is introduced through the needle. tial success of pericardiocentesis yields to the recurrence of cardiac tamponade. ■■ PEARL 12: DRAIN SLOWLY TO AVOID PULMONARY EDEMA ■■ PEARL 11: ANTICIPATE WHAT THE FLUID SHOULD LOOK LIKE Pulmonary edema is an uncommon complication of pericardiocentesis that might be Before performing pericardiocentesis, antici- avoidable. Heralded by sudden coughing and pate the appearance of the pericardial fluid on pink, frothy sputum, it can rapidly deteriorate

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into respiratory failure. The mechanism has When the pericardial fluid has been com- been attributed to a sudden increase in right pletely drained, one must decide how long to ventricular stroke volume and resultant left leave the catheter in. One reason to remove ventricular filling after the excess pericardial the catheter at this time is that it causes pleu- fluid has been removed, before the systemic ritic pain; another is to avoid introducing in- arteries, which constrict to keep the systemic fection. A reason to leave the catheter in is to blood pressure up during cardiac tamponade, observe the effect of medical treatment on the have had time to relax.13 hourly pericardial fluid output. Nonsteroidal To avoid this complication, if the volume anti-inflammatory drugs are the drugs of first of pericardial fluid responsible for cardiac tam- choice when treating pericardial inflamma- ponade is large, it should be removed slowly,14 tion and suppressing production of pericardial stopping for a several-minute rest after each fluid.16 In most cases the catheter should not 250 mL. Catheter removal of pericardial fluid be left in place for more than 3 days. by gravity drainage over 24 hours has been Laboratory analysis of the pericardial fluid suggested.15 A drawback to this approach is should shed light on its suspected cause. Anal- catheter clotting or sludging before all the flu- ysis usually involves chemistry testing, micro- id has been removed. It is helpful to keep the scopic inspection of blood cell smears, cytology, drainage catheter close to the patient’s body microbiologic stains and cultures, and immu- temperature to make the fluid less viscous. nologic tests. Results often take days. Meyers Output should be monitored hourly. and colleagues17 expound on this subject. ■

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