How should the nurse position the client for Pericardiocentesis to treat cardiac tamponade?

Overview

What is cardiac tamponade?

Cardiac tamponade happens when the fluid sac around your heart fills with blood or other fluid, putting pressure on your heart. Because of the pressure, your heart can’t fill up with blood, reducing how much blood your heart can pump and ultimately causing a drop in blood pressure. Trauma and certain diseases can cause cardiac tamponade. If not treated, it is always fatal.

What happens in cardiac tamponade?

Inside your chest, your heart is contained within a sac called the pericardium. The pericardium has two layers and holds your heart in place, and it also contains pericardial fluid. The fluid helps cushion your heart from outside force and stress.

The chambers of your heart have to expand to fill up with blood before pumping blood out. Cardiac tamponade — which is sometimes called pericardial tamponade — happens when the pericardium fills with fluid (especially blood). Because the fluid has nowhere to go, your heart runs out of room and can’t expand enough to fill effectively.

What’s the difference between pericardial effusion and cardiac tamponade?

Pericardial effusion is the technical term for when the pericardium is filling up with fluid. Cardiac tamponade is when pressure from surrounding fluid keeps your heart from beating. Effusions can consist of blood, discharge and other blood components products.

Cardiac tamponade may not happen or will take longer to happen when the pericardium fills up with fluid slowly. This is because it has time to stretch and make more room for fluid, and the process may not cause symptoms. However, cardiac tamponade can still happen even when it takes days, weeks or months for enough fluid to accumulate.

Symptoms and Causes

What causes fluid to surround and compress my heart?

Several different types of injuries can cause cardiac tamponade. For example, it can happen with blunt trauma, such as a fall or a car crash, or penetrating trauma, like a stab wound from a knife.

It can also happen as a result of another injury, such as an aortic dissection. This happens when a tear forms in the wall of the aorta, a major artery in the center of your body. Blood can accumulate in between layers of the aorta’s walls and cause the artery to rupture, filling the pericardium with blood.

Cardiac tamponade is also caused by or linked to several diseases and conditions. These include:

• Advanced cancer.
• Heart attack (especially if the heart wall ruptures).
• Tuberculosis (more common in developing countries).
• Inflammation or infection of the pericardium. This includes both bacterial and viral infections, especially in patients with Human Immunodeficiency Virus (HIV).
• Chronic immune diseases like lupus, rheumatoid arthritis and scleroderma.
• Heart cancer.
• Heart or kidney failure.
• Hypothyroidism (underactive thyroid gland).

In some cases, cardiac tamponade can also happen after a medical procedure. Some of these include:

• Surgery on the heart or near the pericardium.
• Catheter-based procedures that involve the heart or surrounding blood vessels.
• Placement of a device like a pacemaker.
• Radiation therapy near the heart or pericardium.

What are the symptoms of cardiac tamponade?

Cardiac tamponade that happens quickly can cause the following symptoms:

• Sharp pain in the chest. The pain may also radiate or extend to nearby parts of the body like the abdomen, arm, back, neck or shoulder. It may also get worse when you breathe deeply or cough.
• Trouble breathing or breathing rapidly.
• Fainting, dizziness or lightheadedness.
• Changes in skin color, especially going pale, gray or blue-tinted skin.
• Heart palpitations (where you become unpleasantly aware of your heartbeat).
• Fast pulse.
• Jaundice (yellowing of the skin or eyes caused by liver problems).
• Altered mental status. A person with this will not be acting like themselves and may act confused or agitated.

Cardiac tamponade that happens more slowly may also cause these symptoms:

• Shortness of breath.
• Swelling in the abdomen or legs.
• Fatigue or tiredness.
• Chest discomfort that typically gets better when you lean forward or sit up.

Who does cardiac tamponade affect?

This condition can happen to people of all ages. Cardiac tamponade caused by other diseases happens to about two out of every 10,000 people.

How does compression of the heart affect my body?

Cardiac tamponade is dangerous because it ultimately limits the cardiac output, which is the amount of blood your heart can pump. This deprives your body of blood and oxygen. Eventually, it can cause your heart to stop entirely, a potentially fatal condition called cardiac arrest.

Diagnosis and Tests

How is cardiac tamponade diagnosed?

Several different tests and methods can help diagnose cardiac tamponade. However, certain tests are more likely to be used when it happens quickly because they can deliver a fast diagnosis.

Healthcare providers are most likely to diagnose cardiac tamponade using the following:

• Physical exam: This will include taking your pulse, blood pressure and checking your breathing. Your healthcare provider will also listen to your heart and breathing sounds. A provider taking blood pressure may also take longer than usual because they are looking for a symptom called pulsus paradoxus, where your blood pressure drops unusually each time you take a breath.
• Echocardiogram: This test uses ultrasound waves to see inside your chest and heart. In an emergency, an echocardiogram can be done using a portable machine brought to your hospital bed.
• Chest X-ray: An X-ray can show fluid buildup around your heart.
• Computed tomography (CT) scan: An advanced type of scan that uses X-ray and computer technology to examine heart and circulatory problems.
• Electrocardiogram: This test uses sensors that attach to the skin of your chest and detect the electrical activity of your heart.
• Heart catheterization: This test lets providers see inside your heart and blood vessels using a device that’s inserted into one of your arteries and then threaded toward and into your heart.

A hallmark sign of cardiac tamponade is a trio of symptoms known as Beck’s triad:

• Low blood pressure (hypotension).
• Bulging neck veins.
• Heartbeat sounds that are distant or muffled when listening through a stethoscope.

However, Beck’s triad doesn’t always happen when a person has cardiac tamponade, so a lack of these isn’t a guarantee it isn’t happening.

Management and Treatment

How can this condition be treated?

Treating cardiac tamponade requires removing the fluid from around the heart. It may also call for repairing damage (which may have caused or was caused by the fluid buildup). Treatments used include:

• Pericardiocentesis: This procedure uses a needle that's inserted into your chest until it enters the pericardial sac. Imaging guidance, like an echocardiogram or X-ray fluoroscopy, is almost always used for this. It's only done without imaging guidance in an extreme emergency where there’s no other option.
  • After inserting the needle, the fluid inside the pericardium is drawn out. It’s also likely that a catheter will be used to drain fluid over time.
• Surgery: If an injury caused the cardiac tamponade or there’s damage that need to be repaired, surgery may be a better option. This is also an option when a needle can't reach accumulated fluid or when the pericardium needs to be removed.
  • In especially severe cases, such as when the heart stops because of cardiac tamponade, a surgical technique called a thoracotomy may be done by the bedside in the emergency room.

Depending on what caused your cardiac tamponade and how it was treated, you may be given pain medications, antibiotics or other medications.

What complications are possible with cardiac tamponade?

Cardiac tamponade complications can include:

• Shock.
• Heart failure.
• Death.

Pericardiocentesis and surgery can have the following complications:

• Bleeding.
• Injury to the heart’s chambers or surrounding blood vessels.
• Collapsed lung (pneumothorax).
• Air in the pericardium (pneumopericardium).
• Heart attack.
• Infection.
• Irregular heartbeat (arrhythmia).
• Injury to nearby organs, including the liver, lung or stomach.

Prevention

Can cardiac tamponade be prevented?

Because either diseases or injuries can cause it, cardiac tamponade is extremely difficult to predict and prevent. However, it may be possible to avoid it with early detection and treatment of a pericardial effusion, especially after an injury or with conditions that you know you have.

Outlook / Prognosis

How long does it take to recover?

Your healthcare provider can give you guidance on what you should and shouldn’t do while you’re recovering from cardiac tamponade and any procedure used to treat it. If you had surgery, it’s likely that your provider will tell you to avoid physical activity during the healing process.

If a disease is what caused your cardiac tamponade, how you manage it will change depending on your situation. Your provider can guide you on what you can and should do once you go home.

When should I go to the emergency room?

Cardiac tamponade is a medical emergency and needs immediate care. If you have any injury to your chest, especially near your heart, you should seek urgent medical attention. This includes injuries from any impact (where your skin isn't broken) or that penetrate your skin. You should also seek urgent medical attention if you’re recovering from cardiac tamponade and any of the symptoms return.

You should also go to the hospital if you had surgery or pericardiocentesis and you show any symptoms of an infection. These include:

• Fever or chills.
• Around the wound or needle site:
  • Redness.
  • Swelling.
  • Pain.
  • If the wound site is warm to the touch.

A note from Cleveland Clinic

Cardiac tamponade is a serious medical condition, and it is normal to feel fear or anxiety if you or a loved one have been diagnosed with it. Caring for your mental health can be an important part of recovery for you or your loved one. Your healthcare provider can connect you with resources, including counseling or other mental health services, which can help you cope.

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