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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Oncology Emergency Series

When puts the pressure on

By Roberta Kaplow, PhD, APRN-CCNS, AOCNS, CCRN, and Karen Iyere, MSN, APRN, AGNP-C, ACCNS-AG

CARDIAC TAMPONADE, a structural oncologic emergency identified by the Oncology Nursing Society, can occur at any time during the cancer 1.0 trajectory.1 Cardiac tamponade is the compression of the heart due to the ANCC CONTACT HOURS abnormal accumulation of fluid in the pericardial space (pericardial effu- sion), which exceeds normal compensatory mechanisms, impairs cardiac filling, and results in hemodynamic compromise. This article explains why cardiac tamponade occurs, which patients are at risk, how to recognize the signs and symptoms, and how to care for patients with cancer who experience this life-threatening complication.

Anatomic considerations The pericardium, which surrounds and protects the heart, normally contains about 30 to 50 mL of fluid, which decreases friction between the visceral and parietal layers during systole and diastole.1 (See An inside look at the normal pericardium.) Besides serous pericardial fluid, blood, pus, gas, or blood clots may accumulate in the pericardial space. Pericardial effusions may develop slowly (over weeks to months [subacute OURCE S or chronic pericardial effusions]) or rapidly (over minutes to hours [acute 1 CIENCE pericardial effusions]), depending on the underlying cause. For example, /S cancer may cause a chronic whereas chest trauma (such EPHYR Z

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. as a cardiac stab wound) will likely Vasoconstriction increases afterload fail, the patient can experience shock cause an acute pericardial effusion (the pressure the LV must generate to and cardiac arrest.3,5 due to hemorrhage. eject blood into the aorta), which Pericardial effusions can result in increases myocardial workload. The Risk factors impaired cardiac filling, decreased renin-angiotensin-aldosterone system Cardiac tamponade is reported to stroke volume (the amount of blood is also activated, resulting in sodium occur in 5% to 50% of patients with a ejected by the left [LV] with and water retention, which increases cancer diagnosis.1 The risk factors for each systole), and cardiac output preload (the volume of blood that cardiac tamponade can be idiopathic, (CO [the amount of blood ejected by stretches the ventricle at end-diastole) noninfectious, or infectious.5 (See Risk the LV each minute]). 2 The hemody- and additional vasoconstriction.4 factors for cardiac tamponade.) Because namic effects occur because the heart The body’s ability to compensate pericardial effusions can cause cardiac can’t fill and pump effectively.3 for hemodynamic compromise is tamponade, the risk factors for car- Compensatory mechanisms to limited. The more rapidly the peri- diac tamponade include the causes of increase CO include sympathetic cardial effusion develops, the less pericardial effusion. Patients with nervous system activation, resulting likely it is that the body can maintain metastatic mediastinal tumors are at in vasoconstriction and . CO. If compensatory mechanisms high risk for developing cardiac tam- ponade. Cancers likely to metastasize to the heart include chronic myeloid An inside look at the normal pericardium leukemia, Hodgkin and non-Hodgkin The pericardium forms a fibrous covering around the heart, holding it in a fixed lymphomas, melanoma, sarcoma, and position in the thorax and providing physical protection and a barrier to infection. those originating in the esophagus, The pericardium consists of a tough outer fibrous layer and a thin inner serous lung, breast, pancreas, liver, thymus, layer. The outer fibrous layer is attached to the great vessels that enter and leave or stomach.3 the heart, the sternum, and the diaphragm. The fibrous pericardium is highly resis- Some cancer treatments can con- tant to distension; it prevents acute dilation of the heart chambers and exerts a tribute to the development of cardiac restraining effect on the left ventricle. The inner serous layer consists of a visceral tamponade, including chemotherapy, layer and a parietal layer. The visceral layer, also known as the visceral pericardium or epicardium, covers the entire heart and great vessels and then folds over to form radiation therapy, biotherapy (such the parietal layer that lines the fibrous pericardium. Between the visceral and as immunotherapy and gene thera- parietal layers is the pericardial cavity, a potential space that contains 30 to 50 mL py), and some surgical procedures, of serous fluid. This fluid acts as a lubricant to minimize friction between the two such as cardiac surgery valve proce- layers as the heart contracts and relaxes. dures.1 Patients who’ve received more than 4,000 centigray (cGy) Pericardial Fibrous of radiation to the mediastinum are pericardium cavity also at risk for cardiac tamponade, Myocardium depending on the dose of radiation and length of treatment.1 Similarly, Endocardium patients who’ve undergone an extra- pleural pneumonectomy (a surgery- based therapy for malignant pleural mesothelioma) and who’ve received subsequent chemotherapy and radia- tion therapy are at risk.3,6,7 Iatrogenic causes of cardiac tamponade include CPR, cardiac Parietal catheterization, and transvenous 8 pericardium pacemaker insertion. Acupuncture Visceral pericardium has also been reported as a cause of (epicardium) cardiac tamponade.3,7

Recognizing cardiac tamponade Subacute cardiac tamponade (occur- Source: Porth CM. Essentials of Pathophysiology: Concepts of Altered Health States. 4th ed. Philadelphia, PA: ring over days to weeks) may be re- Wolters Kluwer Health; 2015. lated to a neoplastic or a

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. malignant pericardial effusion.8 Risk factors for cardiac tamponade 3,8,15,20 When pericardial effusions develop slowly, as much as 2 L (2000 mL) Idiopathic risk factors may have a viral or autoimmune cause.21 may accumulate without hemody- Noninfectious Infectious namic compromise.9 Patients with • Autoimmune and autoinflammatory, • Viral , such as HIV, Epstein-Barr subacute cardiac tamponade may be such as systemic lupus erythematosus, virus, influenza, varicella, rubella, asymptomatic until the intrapericar- rheumatoid arthritis, Crohn disease, and and hepatitis B virus dial pressure reaches a critical point ulcerative colitis • Bacterial , such as Mycobacte- when signs and symptoms occur. • Neoplasm , such as rhabdomyosarcoma, rium tuberculosis, Salmonella, Acute cardiac tamponade typically metastatic lung or breast cancer, Hodgkin Staphylococcus, Neisseria, and occurs with trauma and has a sud- disease, melanoma, and leukemia Streptococcus species den onset. Less than 250 mL can • Cardiac , such as myocarditis, dissecting • Fungal , such as Candida and cause hemodynamic compromise aortic aneurysm, and pericarditis Histoplasma species when pericardial effusions develop • Trauma , such as blunt or penetrating • Parasitic , such as Echinococcus rapidly because the pericardium chest trauma, and postthoracic surgery and Toxoplasma species can’t expand quickly enough to • Metabolic , such as hypothyroidism and • Infective endocarditis compensate.9 The onset of signs and uremia symptoms and the degree of hemo- • Radiation dynamic compromise depend on • Drugs (rarely), such as procainamide, how rapidly the pericardial effusion isoniazid, hydralazine, dantrolene, anti- develops.3 (See Signs and symptoms of coagulants, fibrinolytics, doxorubicin, and cardiac tamponade.) phenytoin The three classic signs of cardiac tamponade, hypotension, muffled heart sounds, and distended neck Signs and symptoms of cardiac tamponade8 veins, are called Beck’s triad and occur only in a minority of patients with Subacute cardiac tamponade Acute cardiac tamponade acute cardiac tamponade.5,8 Increased • Dyspnea • Chest pain intrapericardial pressure and de- • Chest discomfort or fullness • Tachypnea creased CO cause hypotension. The • Peripheral edema • Dyspnea pericardial effusion muffles heart • Fatigue • Markedly elevated jugular venous sounds. Impaired venous return to • Hypotension with a narrow pulse pressure the heart secondary to increased in- pressure • Venous distension in forehead trapericardial pressure causes neck • Other signs and symptoms of decreased and scalp vein distension.3,10 CO, including decreased mentation, • Hypotension A key diagnostic sign of cardiac oliguria, cool extremities • tamponade in patients with moderate- Cool extremities • to-severe cardiac tamponade is pulsus • Peripheral cyanosis paradoxus, or a large inspiratory de- • Oliguria crease in systolic BP (greater than 10 • Muted heart sounds 11 mm Hg) during normal breathing. • Pulsus paradoxus (See Effects of respiration and cardiac • Sinus tachycardia tamponade on ventricular filling and CO.)5 Pulsus paradoxus should also be suspected if the intensity of the ther hemodynamic compromise, location of pericardial effusion and in patient’s pulse decreases during possibly leading to end-organ dam- assessing its hemodynamic signifi- inspiration.3,12 age and cardiac arrest. cance.8,11 Transthoracic echocardiog- Although cardiac tamponade is a raphy, which is noninvasive, may be Diagnosing cardiac tamponade clinical diagnosis based on the pa- performed at the bedside. Prompt recognition of cardiac tam- tient’s health history and physical ECG findings in a patient with ponade’s signs and symptoms and its assessment findings, two-dimensional cardiac tamponade frequently in- rapid diagnosis are essential because and Doppler echocardiography are clude sinus tachycardia and low QRS delays in treatment can result in fur- important in identifying the size and voltages.8,13 Electrical alternans www.Nursing2017.com February l Nursing2017 l 27

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. (beat-to-beat alterations in the QRS lying cause of cardiac tamponade. effusion. This may be followed by complex) may also be present.8,13 These include a complete blood cell continuous catheter drainage.3 (See Electrical alternans.) count, comprehensive metabolic Preprocedure nursing care of the Although a chest X-ray may be panel, erythrocyte sedimentation patient undergoing pericardiocente- performed to help diagnose cardiac rate, and thyroid panel.1 Cultures of sis includes explaining the proce- tamponade, at least 200 mL of peri- the pericardial fluid may be per- dure to the patient, ensuring the cardial fluid must be present before formed to help determine whether patient has a patent venous access the cardiac silhouette enlarges.8 an infectious source is present. The device, obtaining baseline vital Computed tomography and cardio- pericardial fluid may also be sent for signs, placing the patient in semi- vascular magnetic resonance may cytology to assess for malignant Fowler position to promote fluid also be used to help diagnose cardiac cells.3,5 moving to a dependent position, tamponade, but these studies take and administering sedation and an- longer to perform than a transtho- Management strategies algesia as prescribed. 3,16 racic echocardiogram, and are more Treatment for most patients with car- During the procedure, the nurse costly.3,14 diac tamponade is primarily focused monitors the patient’s vital signs and Although rarely used, cardiac on either percutaneous or surgical clinical status to assess for signs and catheterization may be performed to drainage of the pericardial effusion to symptoms of complications such as diagnose cardiac tamponade. If it’s relieve the elevated intrapericardial dysrhythmias, pneumothorax, coro- used and cardiac tamponade is pres- pressure and restore hemodynamic nary artery laceration, pulmonary ent, equalization of diastolic pres- stability.8,14 Treatment options vary laceration, right ventricular punc- sures will be noted. In addition, in- depending on the severity and cause ture, or cardiac arrest.3,16 Following creased right-sided heart pressures of cardiac tamponade. pericardiocentesis, ensure that a and concomitant decreases in 12-lead ECG and chest X-ray are left-sided heart pressures will be Percutaneous drainage performed. Continue to monitor revealed. A pulsus paradoxus is at- • Percutaneous catheter drainage, vital signs and hemodynamic status tributed to the latter physiologic or pericardiocentesis, with echocar- until drainage is negligible (<25 mL change.8,11 diographic or fluoroscopic guidance, over 24 hours), at which point the is indicated for severely hemody- catheter is removed. Evaluate the Lab findings namically unstable patients.11,15 A patient’s response to treatment to Once the diagnosis has been made, catheter is inserted into the pericar- ensure that signs and symptoms of lab tests may help identify the under- dial space to drain the pericardial cardiac tamponade have resolved.

Effects of respiration and cardiac tamponade on ventricular filling and CO During inspiration, venous flow into the right heart increases, causing the interventricular septum to bulge into the left ventricle. This produces a decrease in left ventricular volume, with a subsequent decrease in stroke volume. In cardiac tamponade, the fluid in the pericardial space produces further compression of the left ventricle, causing an exaggeration of the normal inspiratory decrease in stroke volume and systolic BP.

Pericardium

Left ventricle

Normal Normal Tamponade expiration inspiration (in inspiration)

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Assess the catheter in- sertion site for signs of Electrical alternans infection, including ery- The arrows point to each QRS complex. Note the alternating amplitude of the QRS complexes. thema, edema, increased Every other QRS complex has reduced amplitude alternating with increased amplitude. The most warmth, pain, or puru- frequent cause of electrical alternans is a pericardial effusion. lent drainage.3,16 • Balloon pericardioto- my. This intervention is considered for a recurrent malignant pericardial effusion. An inflatable balloon-tipped catheter is used to develop a path- way for drainage of the pericardial effusion into the mediastinum, reducing pericardial Additional therapies assess for dysrhythmias.16 Anticipate effusion recurrence.3,17,18 Nursing • Volume repletion, or volume ex- preparing the patient for emergent care of a patient undergoing balloon pansion, with agents such as blood, pericardiocentesis with echocardio- pericardiotomy is the same as that plasma, dextran, or saline may be graphic guidance. Prepare for volume described for patients undergoing a needed in patients with cardiac tam- repletion with isotonic solutions pericardiocentesis. ponade until therapeutic pericardial such as 0.9% sodium chloride solu- • Sclerotherapy. Instillation of scle- effusion drainage can be performed.8 tion, or inotropic support with agents rosing agents into the pericardial • Inotropic agents such as dobuta- such as I.V. dobutamine, depending space after pericardiocentesis can mine, with or without vasodilators, on the patient’s hemodynamic status. effectively prevent recurrent pericar- may be used in some patients with Monitor intake and output closely, dial effusions, but it can be very cardiac tamponade to help reverse especially hourly urine outputs. painful for patients. Instillation of hypotension.8 If the patient undergoes percutane- sclerosing agents, such as bleomycin • Sedation, such as midazolam, and ous pericardiocentesis, monitor and and doxycycline, causes scar forma- analgesics, such as fentanyl, may be document the amount and character- tion, leaving no room for pericardial prescribed, depending on the pa- istics of the drainage and obtain speci- effusions to develop.3,14,16 tient’s hemodynamic status.14 mens for lab analysis as prescribed. Nursing care for patients undergo- Monitor the catheter insertion site for ing sclerotherapy is the same as that Nursing interventions signs and symptoms of infection. described for patients undergoing When signs and symptoms related to pericardiocentesis. Because adminis- cardiac tamponade are present, call a Patient education tration of sclerotherapy can be pain- rapid response, immediately notify After assessing patients’ readiness ful, administer sedation and analgesia the patient’s healthcare provider, and and ability to learn, teach them the as prescribed. prepare the patient for diagnostic signs and symptoms (such as short- testing and therapeutic interventions. ness of breath) that might indicate Surgical drainage Nurses have a primary role in moni- recurrent pericardial effusion, and • Pericardiectomy involves surgical toring patients for any deterioration in whom to notify. removal of the entire pericardium clinical status. Keep patients with car- Patients and their families will re- or a portion of it (pericardial win- diac tamponade who are hypotensive quire emotional support and educa- dow) via a median sternotomy or on bed rest with their legs elevated tion about diagnostic and therapeutic thoracotomy.15 Performed less fre- above heart level to increase venous procedures. Catheter site or surgical quently than pericardiocentesis, blood return to the heart.16 Patients wound care instructions should be this procedure relieves pressure who aren’t hypotensive should be provided, as indicated.3 Patients around the heart, allowing it to maintained on bed rest in semi- should be encouraged to maintain contract and relax more freely. A Fowler position or leaning forward.16 adequate hydration and nutrition and pericardiectomy is a treatment Assess for respiratory distress and to implement strategies to promote option for patients with recurrent prepare to administer supplemental relaxation and decrease anxiety.16 malignant pericardial effusions and oxygen as needed. Place the patient Patients also need to be instructed cardiac tamponade.19 on continuous cardiac monitoring to about when to follow up with their www.Nursing2017.com February l Nursing2017 l 29

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. primary care provider or oncologist. 5. Strimel WJ. Pericardial effusion. 2016. http:// 15. Maisch B, Ristic A, Pankuweit S. Evaluation emedicine.medscape.com/article/157325-overview. and management of pericardial effusion in patients Similarly, if a surgical procedure with neoplastic disease. Prog Cardiovasc Dis. 2010; 6. Pass HI, Tsao AS, Rosenzweig K. Initial manage- 53(2):157-163. was performed, follow-up with the ment of malignant pleural mesothelioma. 2016. surgeon should be included. www.uptodate.com. 16. Story KT. Cardiac tamponade. In: Kaplan M, ed. Understanding and Managing Oncologic Emergencies: 7. Ernst E, Zhang J. Cardiac tamponade caused by A Resource for Nurses. 2nd ed. Pittsburgh, PA: acupuncture: a review of the literature. Int J Cardiol. Oncology Nursing Society; 2013:43-68. Stay on alert 2011;149(3):287-289. Cardiac tamponade is a potentially 17. Ruiz-García J, Jiménez-Valero S, Moreno R, 8. Hoit BD. Cardiac tamponade. 2016. www. et al. Percutaneous balloon pericardiotomy as life-threatening complication of can- uptodate.com. the initial and definitive treatment for malignant cer, cancer treatment, or both. High 9. Chandok D, Tighe DA. Pericardiocentesis. In: pericardial effusion. Rev Esp Cardiol (Engl Ed). 2013;66(5):357-363. levels of clinical suspicion are needed Irwin RS, Lilly C, Rippe JM, eds. Irwin and Rippe’s Intensive Care Medicine. 6th ed. Wolters Kluwer/ 18. Jones DA, Jain AK. Percutaneous balloon to identify patients at risk, recognize Lippincott Williams & Wilkins; 2014. pericardiotomy for recurrent malignant pericardial signs and symptoms early, and pro- 10. Yarlagadda C. Cardiac tamponade. 2016. http:// effusion. J Thorac Oncol. 2011;6(12):2138-2139. emedicine.medscape.com/article/152083-overview. 19. Khandaker MH, Schaff HV, Greason KL, et vide therapeutic interventions and al. Pericardiectomy vs medical management in 11. Adler Y, Charron P, Imazio M, et al. 2015 ESC patients with relapsing pericarditis. Mayo Clin Proc. supportive therapies for optimal pa- Guidelines for the diagnosis and management 2012;87(11):1062-1070. tient outcomes. ■ of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases 20. National Cancer Institute. Cardiopulmonary of the European Society of Cardiology (ESC). Syndromes (PDQ)–Health Professional Version. REFERENCES Endorsed by: The European Association for Malignant pericardial effusion. 2016. www. cancer.gov/cancertopics/pdq/supportivecare/ 1. Kaplan M. Understanding and Managing Oncologic Cardio-Thoracic Surgery (EACTS). Eur Heart J. cardiopulmonary/HealthProfessional/page4. Emergencies: A Resource for Nurses. 2nd ed. 2015;36(42):2921-2964. Pittsburgh, PA: Oncology Nursing Society; 2013. 12. Siniorakis E, Arvanitakis S, Hardavella G, 21. Major causes of pericardial disease. Graphic 67851. Version 7.0. www.uptodate.com. 2. Hoit BD. Diagnosis and treatment of pericardial Flessas N, Samaras A, Exadactylos N. Searching effusion. 2015. www.uptodate.com. for pulsus paradoxus and correlates in cardiac tamponade. Int J Cardiol. 2010;145(1):127-128. Roberta Kaplow is an oncology clinical nurse special- 3. Kaplow R. Cancer-related cardiac tamponade. ist at Emory University Hospital in Atlanta, Ga., and 2016. www.inpractice.com/Textbooks/Oncology- 13. Low TT, Tan VS, Teo SG, Poh KK. ECGs with Karen Iyere is a clinical nurse at the Veterans Admin- Nursing/Oncologic-Emergencies/Cardiac- small QRS voltages. Singapore Med J. 2012;53(5): istration Medical Center in Decatur, Ga. Tamponade.aspx. 299-304. The authors and planners have disclosed no poten- 4. Porth CM. Essentials of Pathophysiology: Concepts 14. Schiavone WA. Cardiac tamponade: 12 pearls tial conflicts of interest, financial or otherwise. of Altered Health States. 4th ed. Philadelphia, PA: in diagnosis and management. Cleve Clin J Med. Wolters Kluwer Health; 2015. 2013;80(2):109-116. DOI-10.1097/01.NURSE.0000511804.75711.a5

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