pericardial tamponade

WordNet

1. located around the heart or relating to or affecting the pericardium; "pericardial space" (同)pericardiac
2. blockage or closure (as of a wound or body cavity) by (or as if by) a tampon (especially to stop bleeding) (同)tamponage

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/08/09 23:00:25」(JST)

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Cardiac tamponade
A very large hemorrhagic pericardial effusion due to malignancy as seen on ultrasound which was causing tamponade. closed arrow: the heart, open arrow: the effusion
Classification and external resources
Specialty	Cardiac surgery
ICD-10	I31.9
ICD-9-CM	423.3
MedlinePlus	000194
eMedicine	med/283 emerg/412
Patient UK	Cardiac tamponade
MeSH	D002305

Cardiac tamponade, also known as pericardial tamponade, is an acute type of pericardial effusion in which fluid, pus, blood, clots, or gas accumulates in the pericardium (the sac in which the heart is enclosed), resulting in slow or rapid compression of the heart.

Cardiac tamponade is pressure on the heart muscle which occurs when the pericardial space fills up with fluid faster than the pericardial sac can stretch. If the amount of fluid increases slowly (such as in hypothyroidism) the pericardial sac can expand to contain a liter or more of fluid prior to tamponade occurring. If the fluid effusion occurs rapidly (as may occur after trauma or myocardial rupture) as little as 100 ml can cause tamponade.

Myocardial rupture is a somewhat uncommon cause of pericardial tamponade. It typically happens in the subacute setting after a heart attack, in which the infarcted muscle of the heart thins out and tears. Myocardial rupture is more likely to happen in elderly individuals without any previous cardiac history who suffer from their first heart attack and are not revascularized either with thrombolytic therapy or with percutaneous coronary intervention or with coronary artery bypass graft surgery.

One of the most common settings for cardiac tamponade is in the first 24 to 48 hours after heart surgery. After heart surgery, chest tubes are placed to drain blood. These chest tubes, however, are prone to clot formation. When a chest tube becomes occluded or clogged, the blood that should be drained can accumulate around the heart, leading to tamponade. Nurses will frequently clear clots from the tubes, but even with these efforts chest tubes can become clogged.

Causes

Cardiac tamponade is caused by a large or uncontrolled pericardial effusion, i.e. the buildup of fluid inside the pericardium. This commonly occurs as a result of chest trauma (both blunt and penetrating), but can also be caused by myocardial rupture, cancer, uremia, pericarditis, or cardiac surgery, and rarely occurs during retrograde aortic dissection, or whilst the patient is taking anticoagulant therapy. The effusion can occur rapidly (as in the case of trauma or myocardial rupture), or over a more gradual period of time (as in cancer). The fluid involved is often blood, but pus is also found in some circumstances.

Causes of increased pericardial effusion include hypothyroidism, physical trauma (either penetrating trauma involving the pericardium or blunt chest trauma), pericarditis (inflammation of the pericardium), iatrogenic trauma (during an invasive procedure), and myocardial rupture. One of the most common causes is heart surgery, when post operative bleeding fails to be cleared by clogged chest tubes.

Pathophysiology

Hemopericardium, wherein the pericardium becomes filled with blood, is one cause of cardiac tamponade.

The outer layer of the heart is made of fibrous tissue which does not easily stretch, so once fluid begins to enter the pericardial space, pressure starts to increase.

If fluid continues to accumulate, each successive diastolic period leads to less blood entering the ventricles. Eventually, increasing pressure on the heart forces the septum to bend in towards the left ventricle, leading to a decrease in stroke volume. This causes the development of obstructive shock, which if left untreated may lead to cardiac arrest (often presenting as pulseless electrical activity).

Diagnosis

Initial diagnosis can be challenging, as there are a number of differential diagnoses, including tension pneumothorax, and acute heart failure. In a trauma patient presenting with PEA (pulseless electrical activity) in the absence of hypovolemia and tension pneumothorax, the most likely diagnosis is cardiac tamponade.

Signs of classical cardiac tamponade include three signs, known as Beck's triad. Low blood pressure occurs because of decreased stroke volume, jugular-venous distension due to impaired venous return to the heart, and muffled heart sounds due to fluid buildup inside the pericardium.

Other signs of tamponade include pulsus paradoxus (a drop of at least 10 mmHg in arterial blood pressure with inspiration), and ST segment changes on the electrocardiogram, which may also show low voltage QRS complexes, as well as general signs and symptoms of shock (such as fast heart rate, shortness of breath and decreasing level of consciousness). However, some of these signs may not be present in certain cases. A fast heart rate, although expected, may be absent in people with uremia and hypothyroidism.

In addition to the diagnostic complications afforded by the wide-ranging differential diagnosis for chest pain, diagnosis can be additionally complicated by the fact that patients will often be weak or faint at presentation. For instance, a fast rate of breathing and difficulty breathing on exertion that progresses to air hunger at rest can be a key diagnostic symptom, but it may not be possible to obtain such information from patients who are unconscious or who have convulsions at presentation.

Tamponade can often be diagnosed radiographically. Echocardiography, which is the diagnostic test of choice, often demonstrates an enlarged pericardium or collapsed ventricles. A large cardiac tamponade will show as an enlarged globular-shaped heart on chest x-ray. During inspiration, the negative pressure in the thoracic cavity will cause increased pressure into the right ventricle. This increased pressure in the right ventricle will cause the interventricular septum to bulge towards the left ventricle, leading to decreased filling of the left ventricle. At the same time, right ventricle volume is markedly diminished and sometimes it can collapse.

Treatment

Pre-hospital care

Initial treatment given will usually be supportive in nature, for example administration of oxygen, and monitoring. There is little care that can be provided pre-hospital other than general treatment for shock. A number of the Helicopter Emergency Medical Services (HEMS) in the UK, which have doctor/paramedic teams, have performed an emergency thoracotomy to release clotting in the pericardium caused by a penetrating chest injury.

Prompt diagnosis and treatment is the key to survival with tamponade. Some pre-hospital providers will have facilities to provide pericardiocentesis, which can be life-saving. If the patient has already suffered a cardiac arrest, pericardiocentesis alone cannot ensure survival, and so rapid evacuation to a hospital is usually the more appropriate course of action.

Hospital management

Initial management in hospital is by pericardiocentesis. This involves the insertion of a needle through the skin and into the pericardium and aspirating fluid under ultrasound guidance preferably. This can be done laterally through the intercostal spaces, usually the fifth, or as a subxiphoid approach. A left parasternal approach begins 3 to 5 cm left of the sternum to avoid the left internal mammary artery, in the 5th intercostal space. Often, a cannula is left in place during resuscitation following initial drainage so that the procedure can be performed again if the need arises. If facilities are available, an emergency pericardial window may be performed instead, during which the pericardium is cut open to allow fluid to drain. Following stabilization of the patient, surgery is provided to seal the source of the bleed and mend the pericardium.

In heart surgery patients post op, the nurses monitor the amount of chest tube drainage. If the drainage volume drops off, and the blood pressure goes down, this can suggest tamponade due to chest tube clogging. In that case, the patient is taken back to the operating room for an emergency reoperation.

If aggressive treatment is offered immediately and no complications arise (shock, AMI or arrhythmia, heart failure, aneurysm, carditis, embolism, or rupture), or they are dealt with quickly and fully contained, then adequate survival is still a distinct possibility.

See also

• Pericardial effusion
• Tamponade
• Emergency medicine
• Pulmonary contusion
• Commotio cordis

References

UpToDate Contents

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• 1. 心タンポナーデ cardiac tamponade
• 2. 成人における確定診断を得られていない低血圧やショックの評価および初期アプローチ evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock
• 3. 心膜疾患における奇脈 pulsus paradoxus in pericardial disease
• 4. 心嚢液貯留の診断および治療 diagnosis and treatment of pericardial effusion
• 5. 悪性腫瘍関連心膜疾患 pericardial disease associated with malignancy

English Journal

• Blunt traumatic aortic injuries of the ascending aorta and aortic arch: A clinical multicentre study.

• Mosquera VX, Marini M, Muñiz J, Gulias D, Asorey-Veiga V, Adrio-Nazar B, Herrera JM, Pradas-Montilla G, Cuenca JJ.SourceDepartment of Cardiac Surgery, Complejo Hospitalario Universitario de A Coruña, Spain. Electronic address: Victor.X.Mosquera.Rodriguez@sergas.es.
• Injury.Injury.2013 Sep;44(9):1191-7. doi: 10.1016/j.injury.2012.12.011. Epub 2013 Jan 4.
• OBJECTIVE: To report the clinical and radiological characteristics, management and outcomes of traumatic ascending aorta and aortic arch injuries.METHODS: Historic cohort multicentre study including 17 major trauma patients with traumatic aortic injury from January 2000 to January 2011.RESULTS: The
• PMID 23294894

• Takotsubo cardiomyopathy complicated by cardiac tamponade.

• Ter Bals E, Odekerken DA, Somsen GA.SourceOnze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC, Amsterdam, the Netherlands, edske.terbals@gmail.com.
• Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation.Neth Heart J.2013 Aug 7. [Epub ahead of print]
• We describe a 76-year-old patient with takotsubo cardiomyopathy complicated by cardiac tamponade. Pericardial effusion in takotsubo cardiomyopthy is common but a cardiac tamponade is very rare. The use of anticoagulants may increase the risk of pericardial effusion and should be considered with care
• PMID 23922019

Japanese Journal

• 大動脈弁交連部の限局性解離から生じた心タンポナーデの1例

• 上杉 英之,平山 統一,萩原 正一郎,出田 一郎,押富 隆,高志 賢太郎,片山 幸広,佐々 利明,大森 一史,村田 英隆
• 日本心臓血管外科学会雑誌 44(3), 148-150, 2015
• 症例は68歳男性．意識消失を主訴に救急搬送された．心タンポナーデによるショック状態であったが，CT，心エコー上明らかな大動脈解離を認めず，心嚢ドレナージ術を行った．経過観察中に大動脈径の拡大はないものの，大動脈弁閉鎖不全症が増加した．解離の進展による大動脈弁逆流と考え，発症25日目に手術を施行した．大動脈弁交連部が大動脈壁より剥離・脱落しており，同部位に内膜亀裂を認めたため大動脈基部置換術を施行し …
• NAID 130005078168

• A 型急性大動脈解離の病態と治療成績

• 内田 敬二,輕部 義久,安田 章沢,宮本 卓馬,松木 佑介,磯田 晋,郷田 素彦,鈴木 伸一,益田 宗孝,井元 清隆
• 日本血管外科学会雑誌 24(3), 127-134, 2015
• 要旨：【目的】A 型急性大動脈解離に対する過去20 年間の治療成績を報告する．【対象】当施設において初期治療を行ったA 型解離673 例．【方法】初期治療や手術法，とくに臓器血流障害に対する再灌流先行治療などが現在の方針に確立した2009 年以降225 例を後期，2008 年までの448 例を前期として治療成績を比較検討した．【結果】60 歳未満で男性が，60 歳以上で女性が有意に多かった．血栓閉 …
• NAID 130005072428

Related Links

• Cardiac tamponade: MedlinePlus Medical Encyclopedia

LeWinter MM, Tischler MD. Pericardial diseases. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadlephia, PA: Saunders Elsevier; 2011 ...

• Cardiac Tamponade: Practice Essentials, Background ...

Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical ...

Related Pictures

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★リンクテーブル★

リンク元	「心膜タンポナーデ」
関連記事	「pericardial」「tamponade」

「心膜タンポナーデ」

　　[★]

英

pericardial tamponade

関

心タン・ナーデ

「pericardial」

　　[★]

• adj.

• 心臓周囲の、心膜の、心嚢の

関

cardiac sac、pericardium

　

「tamponade」

　　[★]

• n.

• (症状)タン・ナーデ、(方法)タンポン充填