Summary

Cardiac tamponade is a life-threatening condition caused by accumulation of fluid in the pericardial space, leading to compression of the heart and impaired filling. It is a clinical diagnosis based on haemodynamic compromise — treat urgently with pericardiocentesis. Causes include malignancy, infection (TB, viral), post-MI, trauma, and iatrogenic (post-procedure). Even small effusions can cause tamponade if rapidly accumulating.

Key Facts

• Definition: Pericardial fluid causing haemodynamic compromise
• Beck's triad: Hypotension, Raised JVP, Muffled heart sounds
• Pulsus paradoxus: SBP drop greater than 10 mmHg on inspiration
• Treatment: Pericardiocentesis (urgent) or surgical drainage
• Volume matters less than rate: Slow effusions may reach 1L+ without tamponade
• PEA arrest: Tamponade is a reversible cause (4 Hs and 4 Ts)

Clinical Pearls

Beck's triad is specific but insensitive — you may not see all three

In trauma, tamponade is often from haemopericardium — may need thoracotomy

Electrical alternans (alternating QRS height) is classic but uncommon

Why This Matters Clinically

Tamponade is a treatable cause of PEA arrest and shock. Rapid recognition and drainage saves lives. Echocardiography is diagnostic but should not delay treatment if diagnosis is clinically clear.

Cardiac Tamponade — Emergency Management

Clinical Diagnosis:

• Beck's Triad: Hypotension + Elevated JVP + Muffled heart sounds
• Pulsus paradoxus: SBP drop greater than 10 mmHg on inspiration
• Tachycardia
• Cool peripheries

Immediate Actions:

1. Call for Help

   • Cardiology, Cardiothoracic surgery
   • Prepare for pericardiocentesis

2. IV Access and Fluids

   • Fluid bolus may temporarily improve filling
   • Do NOT over-resuscitate — may worsen tamponade

3. Avoid Positive Pressure Ventilation

   • Reduces venous return, worsens haemodynamics
   • Consider awake pericardiocentesis before intubation

4. Pericardiocentesis

   • Subxiphoid approach (most common)
   • Ultrasound guided (if available)
   • Insert needle towards left shoulder at 45 degrees
   • Aspirate — even 30-50ml may dramatically improve haemodynamics
   • Consider leaving drain in situ

5. Surgical Drainage

   • Indicated if: Purulent effusion, Trauma (haemopericardium), Recurrent effusion, Aortic dissection
   • Pericardial window or pericardiectomy

[!WARNING] In traumatic tamponade, pericardiocentesis is often only a temporising measure. Definitive treatment is thoracotomy.

PEA Arrest

• Tamponade is one of the "4 Ts" (reversible cause)
• Consider if PEA with distended neck veins
• Emergency pericardiocentesis during CPR
• May need resuscitative thoracotomy

History

• Dyspnoea — progressive
• Chest discomfort — may be positional
• Symptoms of underlying cause — fever (infection), weight loss (malignancy), recent procedure

Physical Examination

Beck's Triad:

1. Hypotension (narrow pulse pressure)
2. Elevated JVP (often very high)
3. Muffled heart sounds

Pulsus Paradoxus:

• Measure BP with cuff
• Note SBP when first Korotkoff sound heard on expiration only
• Note SBP when heard throughout respiratory cycle
• Difference greater than 10 mmHg = positive

Other Signs:

• Tachycardia
• Cool, clammy peripheries
• Reduced urine output
• Kussmaul's sign (JVP rises on inspiration) — less common in tamponade

By Size (Echocardiography)

By Haemodynamic Effect

By Aetiology

• Transudative (HF, hypoalbuminaemia)
• Exudative (infection, malignancy, autoimmune)
• Haemorrhagic (trauma, post-MI rupture, dissection)

Key Guidelines

1. ESC Guidelines for Pericardial Diseases (2015) — European standard
2. AHA Scientific Statement on Pericardial Diseases

Evidence Base

• Pericardiocentesis is standard of care for tamponade
• Ultrasound guidance reduces complications
• Surgical drainage preferred for traumatic and purulent effusions

Evidence Levels

What is Cardiac Tamponade?

Cardiac tamponade happens when fluid builds up in the sac around your heart (the pericardium). This fluid presses on your heart and stops it from filling properly, which can be life-threatening.

What Are the Symptoms?

• Shortness of breath
• Chest discomfort
• Feeling faint or dizzy
• Fatigue

What Causes It?

• Infection around the heart
• Cancer
• After heart surgery or procedures
• Injury to the chest
• Inflammation

How Is It Treated?

• Draining the fluid — using a needle (pericardiocentesis) or surgery
• Treatment of the underlying cause
• Close monitoring

After Treatment

• You will have repeat scans to check the fluid doesn't return
• Treatment for whatever caused the fluid buildup
• Follow-up with a cardiologist