Thoracic Trauma - Traumatic Cardiac Tamponade

Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space /sac (Sac surrounding the heart), resulting in reduced ventricular filling and subsequent hemodynamic compromise. It can occur from both a medical and traumatic etiology.  In this post we will discuss Traumatic Cardiac Tamponade. The condition is a traumatic emergency, the complications of which include pulmonary edema, shock, and death.

The speed in which the fluid builds up in the pericardial sac is the largest factor in survival.  The faster the fluid accumulates the higher the mortality.  This is why traumatic cardiac tamponade are often more dangerous than those of a medical cause. Rapid accumulation of as little as 150mL of fluid can result in a marked increase in pericardial pressure and can severely impede cardiac output,^[2] whereas 1000 mL of fluid may accumulate over a longer period without any significant effect on diastolic filling of the heart. This is due to adaptive stretching of the pericardium over time. A more compliant pericardium can allow considerable fluid accumulation over a longer period without hemodynamic insult.

Heart with pericardial sac opened.
 


X-ray showing the heart surrounded by a fluid filled pericardia sac.

Signs and symptoms

Symptoms vary with the acuteness and underlying cause of the tamponade. Patients with acute tamponade may present with dyspnea, tachycardia, and tachypnea. Cold and clammy extremities from hypoperfusion are also observed in some patients. Other symptoms may include the following:

• Elevated jugular venous pressure (JVD)
• Pulsus paradoxus

 

Beck triad

Described in 1935 by Claude Beck, this complex of physical findings, also called the acute compression triad, refers to increased jugular venous pressure, hypotension, and diminished heart sounds. These findings result from a rapid accumulation of pericardial fluid. This classic triad is usually observed in patients with acute cardiac tamponade.

 

The concept was developed by Claude Beck, a resident and later Professor of Cardiovascular Surgery at Case Western Reserve University.^[

 

 

Management

Prehospital treatment.

The prehospital treatment of pericardial tamponade is mainly supportive.  Position of comfort if
thermodynamically stable, semifowlers in in respiratory distress, supine if in hypoperfusion,.  High concentration O2, temperature maintenance, rapid transport to the appropriate facility (trauma center).

In Hospital treatment

Removal of pericardial fluid is the definitive therapy for tamponade and can be done using the following three methods:

• Emergency subxiphoid percutaneous drainage
• Echocardiographically guided pericardiocentesis
• Percutaneous balloon pericardiotomy

The role of medication therapy in cardiac tamponade is limited.


Pericardiocentesis