Pericardial Tamponade question..for a workshop

[mac_kin]

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I know what pericardial tamponade is...rising of pericardial pressure due to fluid in the pericardial sac, which compresses the heart.

I am having difficulty finding articles that outline contraindications for patients with pericardial tamponade.

I'm assuming, once diagnosed, management of this condition would be very quick, as it is life-threatening.

But when first diagnosed, are patients put on bed rest until the fluid is drained? Would it be safe to allow patients to walk/exercise?
I'm saying NO, because I would want to avoid raising the workload of the heart, when the pericardial space is compromised, and thus the heart cannot expand and contract as effectively.

Is this correct? Would there be any other contraindications?

 

[Droopy Snoopy]

I know what pericardial tamponade is...rising of pericardial pressure due to fluid in the pericardial sac, which compresses the heart.

I am having difficulty finding articles that outline contraindications for patients with pericardial tamponade.

I'm assuming, once diagnosed, management of this condition would be very quick, as it is life-threatening.

But when first diagnosed, are patients put on bed rest until the fluid is drained? Would it be safe to allow patients to walk/exercise?
I'm saying NO, because I would want to avoid raising the workload of the heart, when the pericardial space is compromised, and thus the heart cannot expand and contract as effectively.

Is this correct? Would there be any other contraindications?

Pericardial tamponade is a medical/surgical emergency. I find it very curious that you recognize the condition is life-threatening but are still confused if the patient can crank out some squat-thrusts on their way to the cath lab/OR.

 

[tremulousNeedle]

You say pericardial tamponade, but with the lack of urgency you describe, it almost sounds like you are talking about pericardial effusion.

If blood is filling the pericardial sac and causing hemodynamic instability (cardiac tamponade), that needs to be fixed immediately.

There are varying levels of severity of pericardial effusions, which should be easy enough to look up.

 

[Knicks]

Pericardial tamponade is a medical/surgical emergency. I find it very curious that you recognize the condition is life-threatening but are still confused if the patient can crank out some squat-thrusts on their way to the cath lab/OR.

This.

 

[mac_kin]

Actually, I understand the difference between pericardial effusion and tamponade.

Tamponade is classified as generally greater than 200ml of fluid in the sac, which, yes is life-threatening if the filling continues until a point where the heart can no longer beat.

However, the fibrous pericardial sac can stretch to a point. I've actually had patients completely asymptomatic climbing stairs, who hours later were diagnosed with tamponade after they've simply complained of 'chest pain'.

After my workshop however, the MDs did state that yes, if the patient is asymptomatic then you can continue to mobilize them if needed. You obviously wouldn't over stress them, but there is no need for bed rest.

And once diagnosed, the condition will be treated immediately anyway, so usually as soon as diagnosis is made, the patient is on their way to be drained.

Thanks for your smart-ass comment though!

 

[SouthernSurgeon]

Actually, I understand the difference between pericardial effusion and tamponade.

Tamponade is classified as generally greater than 200ml of fluid in the sac, which, yes is life-threatening if the filling continues until a point where the heart can no longer beat.

However, the fibrous pericardial sac can stretch to a point. I've actually had patients completely asymptomatic climbing stairs, who hours later were diagnosed with tamponade after they've simply complained of 'chest pain'.

After my workshop however, the MDs did state that yes, if the patient is asymptomatic then you can continue to mobilize them if needed. You obviously wouldn't over stress them, but there is no need for bed rest.

And once diagnosed, the condition will be treated immediately anyway, so usually as soon as diagnosis is made, the patient is on their way to be drained.

Thanks for your smart-ass comment though!

No actually you don't understand it. Tamponade is a PHYSIOLOGY not a defined quantity of fluid. A patient cannot be in "asymptomatic" tamponade.

As others have suggested you are interchanging the definitions of tamponade and effusion.

I've actually had patients completely asymptomatic climbing stairs, who hours later were diagnosed with tamponade

This is because at time point (a) they merely had an effusion (when they could climb stairs asymptomatically); at time point (b) the effusion had progressed to the point where they were symptomatic and developed tamponade physiology.

 

[MeRLin443]

The way I learned it was that an effusion can turn into tamponade (subacute) or present w/ acute tamponade. I guess that the only difference b/w effusion and subacute tamponade was hemodynamic effects- at least in my mind.

But to answer the OP's question- the only supportive measures are maintain volume status. No diuretics, no vasodilators, and maybe even a bolus can increase CO.

 

[tremulousNeedle]

No actually you don't understand it. Tamponade is a PHYSIOLOGY not a defined quantity of fluid. A patient cannot be in "asymptomatic" tamponade.

As others have suggested you are interchanging the definitions of tamponade and effusion.

This is because at time point (a) they merely had an effusion (when they could climb stairs asymptomatically); at time point (b) the effusion had progressed to the point where they were symptomatic and developed tamponade physiology.

This is exactly correct, cardiac tamponade is a clincal diagnosis not a volumetric or imaging diagnosis.

In the OP's original statement:

I know what pericardial tamponade is...rising of pericardial pressure due to fluid in the pericardial sac, which compresses the heart.

This is not true as you worded it; at the end you would need to add "... which compresses the heart and leads to hemodynamic instability," basically shock. What you wrote could have been simply describing a pericardial effusion.

Once cardiac tamponade is identified virtually everything is contraindicated (besides airway maintenance, ventilatory support, and IV fluids if necessary) since this is a life-threatening condition that needs to be treated immediately (like all other forms of shock). I understand that there can be varying degrees of tamponade; however, this window is narrow. Once a pericardial effusion or hemopericardium turns into tamponade, treatment is urgent (at least trauma surgeons and emergency medicine physicians treat this emergently, but this could be due to the mechanisms of injury that those doctors are likely to see).

If the OP is looking for a source refer to any trauma surgery textbook, emergency medicine textbook, or the ATLS (advanced trauma life support) textbook.

 

[Rendar5]

AS others have said, tamponade is physiologic/clinical, and is simply an effusion that compresses the heart lowering cardiac output. It can occur with any amount of fluid in the pericardial sac. once properly diagnosed, needle decompression is required. They can also take a fluid bolus, but that should not in any way whatsoever push back the pericardiocentesis.

 

[Droopy Snoopy]

Thanks for your assistance in correcting my mistake prior to getting thoroughly roasted on cards rounds though!

Fixed that for you.

And you're welcome.

 

[dpmd]

Actually, I understand the difference between pericardial effusion and tamponade.

Tamponade is classified as generally greater than 200ml of fluid in the sac, which, yes is life-threatening if the filling continues until a point where the heart can no longer beat.

However, the fibrous pericardial sac can stretch to a point.

As others have pointed out, you have either misunderstood or been instructed incorrectly. It is kinda like saying a tension pneumothorax is a pneumothorax that compresses X% of lung. A certain volume of fluid or air may be associated with compressive effects, but that doesn't make the diagnosis for you. It is the physiology of the patient that lets you know what is going on. Someone with tamponade wouldn't have to be placed on bedrest, because they are already going to be in bed trying not to die.