Heart tamponade

Cardiac tamponade is a condition of reduced cardiac output due to mechanical compression of the heart.

[1], [2]

What causes a cardiac tamponade?

• A recent heart surgery, especially if:
  • after the operation, the bleeding from the drains was massive;
  • the pleura during the operation was not opened;
  • the operation was repeated.
• Trauma of the chest (dull or penetrating).
• Coagulopathy (both hyper- and hypocoagulation).
• Hypothermia.

How does the cardiac tamponade manifest?

• Systemic hypotension with increase and equalization of ventricular filling pressures (PP (CVP) and LP (DZLK)); decrease in pulse pressure, increased pressure in the external jugular vein; pulsus paradoxus; the absence of a "y" - a decrease in the pulse wave of the central vein.
• Oliguria. Decreased peripheral perfusion, cyanosis, metabolic acidosis, hypoxemia.
• Dispnoe / "resistance" to the respirator.
• Sudden decrease or disappearance of blood actively flowing through the pleural drainage in the patient after heart surgery.
• Heart failure.

How is the cardiac tamponade recognized?

• Radiography of the chest (dilated mediastinum).
• ECG (low voltage, electrical alternations, changes in the T wave).
• Echocardiogram / transesophageal doppler (pericardial fluid accumulation, reduced, non-filling ventricles).
• Flotation catheter of the pulmonary artery (low cardiac output, systemic vasoconstriction, high DZLK).

Differential diagnosis

• Stressed pneumothorax.
• Cardiogenic shock / myocardial insufficiency / myocardial infarction.
• Pulmonary embolism.
• Excess transfusion, fluid overload.
• Anaphylaxis.

[3], [4], [5], [6], [7], [8], [9]

What should I do if there is a cardiac tamponade?

• Respiratory tract - respiration - blood circulation ... 100% 02.
• Assess the state of vital functions.
• Establish adequate venous access, if this has not been done before, to initiate intravenous fluids, inotropic support.
• After heart surgery - release / "sdit" drainage tubes, try to remove clots from their lumens by suction with a soft catheter. Call the surgeons; to warn the operating room; prepare to open the chest (if necessary - in the cardiac ward of awakening).
• If there is a penetrating foreign body, DO NOT remove it.
• Initiate anesthesia before opening the thorax: the technique should support sympathetic tone (eg, etomidate / ketamine; suksamethonium / pancuronium; fentanyl); as soon as the thorax is opened - intubation and ventilation will be required; Be ready to open the chest (wire cutters) immediately after induction.
• If hemodynamics can not be controlled, immediately open the thorax.
• Pericardiocentesis will help to gain time and mitigate hemodynamic catastrophe.
• Order blood and clotting factors if necessary.

Further management

• Maintain filling pressure and sympathetic tone; avoid bradycardia.
• The use of vasodilators is debated.
• Expect a sharp jump in blood pressure immediately after opening the thorax and removing tamponade; usually after evacuation of the content of the mediastinum, stabilization of hemodynamics follows quickly.
• Make sure that the surgeon has found a source of bleeding and freed the drainage from the clots.
• Correct metabolic acidosis.
• Ventilation can worsen the tamponade and aggravate hypotension.
• If the chest has been opened - repeat antibiotics.

Pediatric features

• Tamponade of the heart can occur when a very small amount of blood enters the mediastinum.
• Cardiac tamponade can be completely sudden and immediately manifest as a cardiac arrest.
• Increased risk for cyanotic conditions, complicated repeated operations and violations of coagulation in combination with stagnation in the liver.

Special Considerations

Electrical alternatives - displacement of the QRS axis from contraction to contraction is accompanied by mechanical swinging of the heart in a large volume of accumulating fluid. It is patognomonic for such a condition as tamponade of the heart, although it is not always observed.

After heart surgery, there should be a high degree of alertness to the populism of such a pathological condition as cardiac tamponade.

The final diagnosis is possible only after opening the chest - even a small accumulation of fluid in the pericardium, determined by echocardiography, can have significant hemodynamic effects if it squeezes the right atrium.

The diagnosis of cardiac tamponade can be very difficult, especially if there is a chance of failure or overload.

Severe impairment of coronary blood flow can cause myocardial ischemia, which further complicates the diagnosis. The clinical picture can unfold both slowly and very quickly. Patients with hypocoagulation have a higher probability of hemorrhage into the pericardium. In patients with hypercoagulability, thrombosis of pleural drains is more likely (NB: the use of aprotinin in severe postoperative bleeding can cause thrombosis of drains).

With penetrating wounds of the heart, including stabbed and gunshot, the patient must immediately be transferred to the operating room and the pericardial opening should be performed. Percutaneous drainage is usually not effective - it should be left for situations where surgery is not possible.