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00152193-201702000-00008.Pdf 24 l Nursing2017 l Volume 47, Number 2 www.Nursing2017.com Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Oncology Emergency Series When cardiac tamponade 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 pericardial effusion whereas chest trauma (such EPHYR Z www.Nursing2017.com February l Nursing2017 l 25 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 ventricle [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 tachycardia. 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 pericarditis or a 26 l Nursing2017 l Volume 47, Number 2 www.Nursing2017.com 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 • Sinus tachycardia 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
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