What is cardiac tamponade hemotamponade causes and treatment

Nature cunningly provided for a kind of protection of the heart muscle, “putting” it in the outer shell – the pericardium. This “clothing” protects the heart muscle from mechanical influences, infectious agents, the first to meet them in its path. It envelops the heart loosely, and normally there is a cavity between the pericardium and the heart.

The cavity has a small amount of a special fluid of serous origin, a kind of lubricant that facilitates the friction of the pericardial leaves, its a little 20-25 milliliters. The outer shell or heart bag also supports the cardiac “motor” – it prevents its displacement relative to other organs, does not allow it to overstrain and stretch unnecessarily during operation. These are important functions of the outer heart membrane.

The heart and the initial sections of large vessels are placed in the pericardial sac formed by pericardial leaves. In her cavity is a clear, light liquid. It is necessary to facilitate sliding movements during heart contractions. The amount of liquid sufficient for “lubrication” is 20–30 ml.

It was found that the heart bag is very stable: it can withstand a pressure of about 2 atm and accommodate up to 1 liter of liquid with a gradual flow. The main task of the bag is to protect the myocardium from overstretching. However, rapid filling even with a volume of 200 ml causes a sudden increase in pressure inside the pericardial leaves, compresses the myocardium, its neuromuscular apparatus, and large vessels.

It is known that in the veins of the chest and the right atrium, the pressure is maintained negative to ensure a physiological suction effect. An increase in pressure due to compression of the mouth of the vena cava violates the filling of the heart in the diastole phase, leading to circulatory disorders.

The causes of cardiac tamponade are due to major damaging factors.

Diseases with increased effusion in the heart bag (hydropericardium) cause pericardial effusion. Depending on the characteristics of the liquid, it is called:

Other forms are possible. Pericarditis is most common with:

  • rheumatism;
  • tuberculosis;
  • renal failure with azotemia, uremia;
  • infectious diseases (typhoid, dysentery, tularemia, measles, erysipelas, syphilis, cholera, tonsillitis, meningitis);
  • leukemia, lymphogranulomatosis;
  • severe fungal infection – actinomycosis.

Injuries of the chest organs are accompanied by fractures of the ribs, sternum, rupture of soft tissues and blood vessels, wound of the pericardium

Cardiac tamponade with blood (hemopericardium) can occur with a violation of the integrity of the myocardium, aorta, vena cava during:

  • chest injuries;
  • rupture of the aorta with stratified aneurysm;
  • heart rupture as a result of transmural extensive heart attack;
  • surgical intervention on the heart.

Bleeding in the pericardial bag occurs when:

  • a decaying malignant tumor with germination from neighboring tissues (lung cancer, breast cancer);
  • complication of anticoagulant therapy due to a sharp decrease in coagulability;
  • blood diseases with thrombocytopenia;
  • exposure to high doses of radiation.

A more rare reason is the accumulation of air in a closed heart bag (pneumopericardium). Only in 10% of cases it occurs in isolation. Usually, the pressure inside the lung tissue should increase significantly beforehand. Pathology is observed with:

  • wounds to the chest, barotrauma;
  • medical procedures (sternal puncture, tracheal intubation, endoscopy, mechanical ventilation with increased pressure on the exhale), cases of pneumopericardium in a child after tooth extraction have been described;
  • the formation of a fistula (messages with a hollow organ) with the esophagus with peptic ulcer, with a lung (as a result of staphylococcal pneumonia, a protracted attack of asthma), with a transverse colon with a subphrenic abscess;
  • in 2% of premature infants.

Violation of the normal contraction of the heart muscle always has severe hemodynamics. This pathology is called cardiac tamponade. The process of obstructing the work of the atria and ventricles is caused by the accumulation of fluid in the voids between the leaves of the pericardium.

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What’s this

Cardiac tamponade is always a progressing process; it cannot stop by itself; it cannot. The most common causes of tamponade, not related to injury, are pericarditis of the heart: tumor, uremic, idiopathic.

The origin of the liquid influx may be different, but the result is always the same. Against the background of inflammation, edema is rapidly developing, which often leads to acute heart failure, up to a complete cessation of cardiac activity.

The heart is normal and with tamponade

Development

In the normal, working state of the myocardium, the heart bag contains no more than forty ml. liquids. Exceeding this limit already leads to significant violations reaching the upper mark at the level of 200-250 ml.

However, there are also chronic forms of the disease in which the accumulation of up to one lira of fluid is possible. This is typical for small and gradual flow of fluid into the heart bag. The cavity is slowly stretched, getting used to a new state and the criticality limit is temporarily moved away.

It is impossible to predict how the disease will develop. In order to make forecasting, one would not only have to take into account too many factors, but also know the body’s response to each of these factors. And the endurance of the body and the limit of its ability are individual for each person.

Causes

Cardiac tamponade is not a consequence of genetic disorders and is not inherited. She always has an adequate origin.

The reasons for the development of cardiac tamponade can be the following:

  • Any open damage to the chest wall – it can be a penetrating wound, a strong directed blow;
  • The consequences of surgery on the myocardium, which led to hemorrhage;
  • Rupture of the aorta;
  • Acute, prolonged diseases of pericarditis with viral or idiopathic etiology;
  • Tuberculosis diseases of various forms;
  • Cancers in the lungs or mammary glands;
  • Lymphomas
  • Hemodialysis, expressed by renal failure;
  • The effects of radiation exposure;
  • The consequences of injuries.

Any of the above diseases can cause fluid to flow into the cavity of the heart bag. There are frequent situations when the causes of cardiac tamponade remain undetected even after the operation.

Symptoms

It happens that tamponade of the heart does not manifest itself for quite a long time. The lack of treatment entails the development of internal processes, the accumulation of complications and, at some point, the disease is exacerbated by pericarditis, that is, inflammation of the heart tissues.

All this happens due to the ignoring of certain emerging signs caused by a decrease in cardiac output and a violation of the correct pulsation of the heart muscle.

Among the most obvious symptoms of heart tamponade, which will talk about actual changes, are present:

  • Discomfort, discomfort, and chest pain;
  • Obsessive feeling of anxiety;
  • Shortness of breath without physical effort;
  • Arterial hypertension;
  • Feeling of relaxation, with dizziness;
  • Sharp sweating, pallor of the skin;
  • Pressure reduction;
  • Weak pulsation of the myocardium, giving off in dull tones.

Reducing blood pressure, venous hypertension and deaf heart tones – in the aggregate, can talk about the “classic Beck triad.” In other words, the causes of the last 3 points, most often is a heart injury, with subsequently developed cardiotamponade.

Other symptoms and signs of tamponade can be easily confused with common signs of heart failure:

  • Loss of appetite, state of weakness, lack of desire to move, take some kind of action;
  • Pressing sensations in the hypochondrium on the right side;
  • Interruption of breathing (symptoms of shortness of breath), forcing a person to periodically sit down, lean against the wall, seek support to catch his breath;
  • Enlargement of the liver;
  • The formation of fluid reserves in the peritoneum.

If even if there are several symptoms from the top two lists, the patient did not seek medical help, there is an increase in symptoms: general arousal increases, memory impairments are possible. Shortness of breath takes on a constant character, swelling of the veins of the neck occurs. With a further delay in treatment, in the form of a pericardocentesis procedure, a person dies.

What is characteristic, multiple complaints of patients during this period of the disease practically exclude heart pain. Patients are much more concerned with the external manifestations of the disease, in the form of coughing, a “voiced” voice. However, these symptoms are nothing more than a reflection of the true causes affecting the esophagus, pulmonary system, trachea and nerve endings of the larynx.

During the study, an increase in venous pressure, tachycardia is detected. A very characteristic phenomenon in this case is the so-called fact of a paradoxical pulse. That is, the pulse pressure decreases with each breath by 10 mmHg, at least.

Diagnostics

Diagnosis of cardiac tamponade involves palpation and hardware examination. Both types of research are equally equal in importance, since, often, direct contact examination forms the basis of a correct diagnosis.

  • Physical examination during the initial examination, may state in the patient: cardiac tachycardia; frequent shallow breathing; drop in blood pressure; mental disorders (agitation or apathy): cyanosis of the mucous membrane and skin; deaf heart tones; the inability to feel the pulse, or its weak trapping during inhalation, and a sharp increase in pulse waves on the exhale.
  • A radiographic examination, in the case of an illness, shows a greatly enlarged heart shadow with a subtle pulsation with the same chest size. If the heart circuits do not go beyond the norm, then there is a slight accumulation of fluid. It happens that an x-ray shows a changed shape of the heart muscle: round, triangular, or having a straightened outline on the left;
  • On the results of ultrasound (ultrasound) of the myocardium, with a confirmed diagnosis, the presence of fluid in the cavity between the pericardial sheets is clearly visible.
  • On the ECG, the ambiguous effects of tamponade are clearly visible: sinus tachycardia and a decrease in voltage.

The causes of two pathologies

As already mentioned, the essence of the pathological process is the compression of the actual cardiac structures by exudate or blood.

Tamponade develops as a result of several points. The most common option is a chest injury with damage to the heart or pericardium. There is a mass effect.

Normally, the amount of serous fluid in the bag’s cavity is 25 ml or slightly less, depending on the size of the organ (in women, the volume is lower).

As soon as the pressure indicator in the pericardium is compared with that in the ventricles, cardiac arrest occurs without the possibility of urgent resuscitation. This is almost a guaranteed death of the patient.

Depending on the type of contents of the bag, two forms of the pathological process are distinguished:

  • Hemotamponade. Clinically less common. It is characterized by the release of blood into the pericardium. Volumes depend on the outflow intensity.

It can develop as a result of a heart attack, chest injuries, rupture of large vessels. Associated with a worse prognosis, because in addition to heart compression, bleeding is also observed.

As part of urgent surgical treatment, it is necessary to immediately eliminate both conditions, which is not so simple even for an experienced doctor. The risk of death is 60%. With a sharp increase in the volume of blood entering the pericardium – almost 100%.

  • Exudative form. As the name implies, the discharge accumulates. What kind – doctors have to find out.

The effusion is formed as a result of inflammatory processes in the pericardium or cardiac structures.

There is more time for quality therapy. The exception is cases of extremely aggressive variants of the infectious process. The account goes to the clock.

Regardless of the form, the therapy is strictly inpatient, urgent. Using operational methods. Only then do doctors understand the situation in more detail and supportive treatment is prescribed.

During the pathological process, generalized circulatory disorders are observed throughout the body. An approximate mechanism of whatever type is characterized by such phenomena:

  • The capacity of the right heart is significantly reduced.
  • The pressure in the veins of a large circle is growing.
  • Since liquid connective tissue is not able to move freely through the vessels, cardiac output is reduced. Also, this is observed due to compression of cardiac structures, which are on the verge of stopping.
  • The supply of oxygen and nutrients to all body tissues decreases. The kidneys, liver, brain, and also the myocardium suffer. Ischemia, hypoxia occurs.
  • In the long term of several hours or a maximum of a day, acute multiple organ failure begins. If the patient has not died of cardiac arrest, the likelihood of death as a result of a disruption in the activity of a particular system is maximum.

Response time is usually not enough. Therefore, many patients (about 40%) die in the first few days from the start of the process.

Diagnosis is not difficult, but there are cases of posthumous determination of the onset of death.

This is the most common type of pathological process. It is treated effectively because a sufficiently long manifest period is present.

An approximate list of factors:

  • Diabetes mellitus in the phase of serious decompensation.
  • Disorders of the thyroid gland.
  • The terminal stage of renal failure. In this case, the mechanism of small liquid evacuation comes into play. The paired organ is no longer capable of filtering. Hence the generalized disturbances in the operation of systems, the heart suffers first.
  • Rheumatism. Inflammatory pathology leading to destruction of cardiac structures. Also, other autoimmune processes (systemic lupus erythematosus, sclerosis).
  • Tumors of a benign and malignant nature. Especially localized in the pericardium itself. As the cells die, pathological exudation occurs. This is a kind of defense mechanism. Against the background of cancer, such a phenomenon is expressed to the maximum extent. Even with competent, comprehensive treatment in a hospital, the chances of survival are not high, due to the resistance of cardiac tumors to therapeutic methods.
  • Defeat the heart and bags with fungal agents. The most famous and widespread is candid. The disease is sporadic. It may be the result of pathologies of the throat, respiratory tract. The main role in the development of infectious phenomena is given to reduced immunity.
  • Bacterial diseases. In the vast majority of cases, we are talking about tuberculosis (approximately 90% of recorded situations). The likelihood of such an outcome is maximum in untreated patients or with insufficiently effective therapy. A slightly smaller role is given to genital infections. They are characterized by extreme aggressiveness, the ability to transport throughout the body and affect distant structures. Gonococci, pale (syphilitic) spirochetes of chlamydia and ureaplasma.
  • Viral pathology. Of particular importance is the herpes of several strains (simple, genital, Varicella-Zoster, Epstein-Barr, fifth type, etc.). Also, agents that provoke rubella, mumps and AIDS are capable of involving the pericardium in the process.

Exit exudate is relatively simple to stop. Moreover, the process lasts long enough.

The reasons are always serious. The development of the state takes a few minutes, less often hours.

  • Extensive heart attack with a violation of the anatomical integrity of the heart.
  • Penetrating and closed wounds of the chest.
  • Surgical interventions on cardiac structures, diagnostic measures (including minimally invasive ones). There is always a risk of such a traumatic outcome, although not a big one.

Reacting on time is almost impossible. Amid massive bleeding, compression is an additional lethal factor that reduces the chances of survival to almost zero.

Symptoms of tamponade

Characteristic features are formed gradually, as the process progresses. Among the possible manifestations:

  • Enlarged liver as a result of rapidly developing failure.
  • Ascites or accumulation of fluid in the abdominal cavity.
  • Drop in blood pressure. Not to critical levels, the approximate figures for normotonic are determined by the interval from 90 to 100 per 60-70 mm of mercury.
  • Cyanosis of the skin, nasolabial triangle.
  • Tachycardia. Paradoxically, against the background of accelerating cardiac activity, the pulse is weakening, which indicates the inefficiency of the compensatory mechanism.
  • Enlarged, swollen veins in the neck.
  • The surface of breathing, possibly its rapidity against the background of complete rest.
  • Weakness, drowsiness.
  • Pain in the chest, feeling of pressure, heaviness.

Symptoms of cardiac tamponade of the exudative type gradually increase. This determines the relatively high chances of successful treatment and saving lives.

In this case, the clinical picture develops in a matter of minutes or hours, depending on the amount of blood loss and the release of liquid tissue into the pericardium.

  • Syncopal condition. Fainting. Its depth depends on the nature of pathological changes. Usually bringing a patient to feelings is almost impossible. And with success, relapse occurs. It ends with a stupor, a coma.
  • Intense, unbearable chest pain due to rupture of the myocardium or large vessel. Against the background of the injury, a similar phenomenon may not be noticed.
  • Tachycardia with a general weak pulse. The heart rate is 100-120 beats per minute and higher.
  • Pallor of the skin, cyanosis of the nasolabial triangle. The “acute” patient looks like a wax figure.
  • Tachypnea. A typical sign of hemotamponade is increased breathing with a paradoxical pulse: at the time of air intake, it disappears and is not fixed.
  • A pronounced drop in blood pressure. The level is close to critical. As the process progresses, the tonometer readings continue to decline. Pronounced hypotension itself may result in fainting, coma. The death of man.
  • Swelling of the vessels of the neck. Evidence of increased pressure in the veins.

The second option for an emergency is called hemopericardium or blood accumulation in the pericardial sac.

Diagnostics

Cardiologists or specialized surgeons are involved in the management of patients with suspected tamponade. Patients are often delivered by ambulance, less often hospitalized on a planned or urgent basis (with exudative form). You need to examine a person quickly, every minute counts.

Sample list of events:

  • Initial inspection. There is a decrease in the intensity of a heart beat or a complete absence thereof.
  • Listening to the sound. The deafness of tones, unevenness is determined. Signs of arrhythmia are possible.
  • Blood pressure measurement. Against the background of the process, it is reduced. Also heart rate. This is a pronounced tachycardia. When trying to feel the pulse, problems are possible: the intensity of the waves is insufficient for accurate fixation of the indicator.
  • Electrocardiography It determines multiple nonspecific deviations of functional activity, including: deformation of all teeth, broadening of the QRS complex, and others. Pronounced arrhythmia of various types is observed.
  • Echocardiography. Determines the expansion of the boundaries of the muscular organ. Fluid in the pericardium is also fixed. This is the main symptom of the pathological process. Additionally visualized vascular damage. ECHO-KG is considered the gold standard for the diagnosis of cardiac tamponade.
  • Chest x-ray. To verify the diagnosis and determine the exact size of the cardiac structures.

After first aid, the same methods (through echocardiography) are used to evaluate the effectiveness of treatment.

A favorable outcome does not guarantee survival, but gives hope. It is important to control the dynamics of the process every few hours, then the frequency becomes less frequent.

Controversial cases require extensive diagnosis. If possible, MRI is prescribed. This method puts an end to the question of the origin of the phenomenon.

Detailed images show all the anatomical defects of the cardiac structures. Perhaps the use of a contrast drug based on gadolinium.

Causes of tamponade

Pathology groupSpecific diseases
Viral lesionsHerpes of any type
Bacterial diseasesTuberculosis in 75–80%Fungal infectionsCandidiasisMalignant tumorsPrimary neoplasms of the heart muscle

Metastatic spread of cancer of the breast, stomach, colon, melanoma

Autoimmune pathologiesSystemic lupus erythematosusMetabolic disordersInadequate kidney function in the terminal phase

Adrenal and thyroid insufficiency

2
When the “clothes” are not in size or how the tamponade develops

Let’s figuratively imagine what happens to the heart with tamponade . How would you feel in clothes 2 sizes smaller? You would be cramped. You would not be able to carry out the daily workload, at first you would apply maximum effort to do the work, and then, tired, take it off, tear it apart, could not bear the discomfort . The heart also feels with tamponade, since in this condition there is an excessive accumulation of fluid in the pericardial cavity .

When this cavity is filled with liquid, the pressure in it rises, the heart becomes compressed, its ability to contract decreases, the venous inflow to it decreases, and cardiac output decreases. Cardiac tamponade is a life-threatening complication of pathological conditions on the part of the cardiovascular system. How quickly this condition progresses depends on the rate of fluid accumulation and its volume in the pericardial cavity.

If the accumulation of fluid occurs quickly, then even 230-240 ml of fluid is sufficient for the development of tamponade, with a slow accumulation of fluid, the pericardium has time to stretch, adapt, and the tamponade occurs when the fluid volume exceeds 2 liters, and sometimes even 3 liters can fit in a heart bag . A tamponade can develop rapidly, dramatically, literally in a couple of hours, or even within a few minutes, in some cases it develops slowly, and then we are talking about subacute compression of the heart.

But regardless of the rate of compression to which the cardiac muscle is subjected, the mechanisms of its development are the same: the pressure inside the pericardial is rapidly increasing, pressure by the liquid causes a decrease in the volume of the left ventricle and other heart chambers, an increase in diastolic and a drop in systolic pressure of the ventricles, a sharp decrease in the volume of shock, cardiac ejection.

So what causes the compression of the heart muscle? What diseases and pathological conditions can lead to a life-threatening disorder?

Cardiac tamponade: causes. symptoms and treatment

The causes of cardiac tamponade are conditions that lead to the accumulation in the pericardial cavity of a liquid of biological origin (blood, pus, effusion, lymph, exudate and the like).

Most often in clinical practice, acute cardiac tamponade is diagnosed, which develops against the background of hemorrhage in the intrapericardial space, which is characteristic of the following pathological processes in the body:

  • mechanical damage to the chest with penetrating wounds of the membranes of the heart;
  • poorly performed medical diagnostic and therapeutic measures (probing and catheterization of the heart muscle, surgery, myocardial biopsy);
  • dissection of the aortic aneurysm;
  • hemorrhage into the pericardial cavity after myocardial infarction, which was accompanied by spontaneous rupture of the heart wall;
  • long-term use of medications from the group of anticoagulants.

There are other reasons for cardiac tamponade, when a certain amount of serous or purulent exudate, effusion, and the like accumulate in the intrapericardial space:

  • infectious pericarditis and myocarditis;
  • chronic lung diseases that are accompanied by respiratory failure (tuberculosis, bronchiectasis, lung cancer);
  • acute and chronic renal failure;
  • malignant tumors of the chest cavity and metastasis;
  • lymphomas in the chest cavity;
  • systemic and endocrine diseases (myxedema, lupus erythematosus, scleroderma).

Depending on the duration of the development of the pathological condition and the severity of symptoms, it is customary to distinguish acute and chronic cardiac tamponade. Acute cardiac tamponade occurs suddenly and is characterized by a pronounced clinical picture, frequent signs of which are:

  • pain and discomfort behind the sternum, which is accompanied by a fear of death;
  • a sharp decrease in blood pressure, cold sweat, fainting state, as a manifestation of a shock state;
  • increasing shortness of breath, rap >

According to experts, the Beck symptom triad, which includes visual expansion of the veins in the neck, a decrease in blood pressure and dull heart sounds, is a classic manifestation of acute cardiac tamponade.

Sometimes the Beck triad may be the only confirmation of the development of a pathological condition and indicate accumulation of fluid in the pericardial cavity, in the absence of other manifestations of the disease.

For cardiac tamponade, the symptoms of which develop gradually, it is characteristic:

  • shortness of breath during physical exertion, and with time and at rest;
  • general weakness, loss of working capacity;
  • appetite disturbance;
  • accumulation of free fluid in the abdominal cavity (ascites);
  • enlarged liver;
  • heaviness and discomfort in the right hypochondrium;
  • persistent arterial hypotension;
  • pallor of the skin.

First of all, if a pathological condition is suspected, the doctor examines the patient, in which he identifies the specific symptoms of the disease and identifies the main syndromes. Further, in order to accurately determine the signs of cardiac tamponade, the following clinical and laboratory tests are prescribed to the patient:

  • electrocardiographic examination allows you to determine some nonspecific signs of the disease, exclude the occurrence of sinus tachycardia or confirm the decrease in voltage, myocardial infarction (read more here);
  • ultrasound or echocardiography is by far the most effective and fastest method for diagnosing cardiac tamponade, with which you can confirm the presence of free fluid in the pericardial cavity, diagnose hemodynamic disorders, as well as collapse of the right heart and the presence of myocardial ischemia;
  • X-ray diagnostic methods are able to determine the extended borders of the heart and the roundness of its shape, as well as confirm the absence of venous congestion in the lungs.

Cardiac tamponade refers to complex emergency conditions, the treatment of which is carried out in an intensive care unit.

To remove excess fluid from the pericardial cavity, the patient is punctured pericardial space under local anesthesia.

The extracted exudate is necessarily sent to the laboratory for bacteriological and cytological studies, the further management tactics of the patient depend on the results of which.

In order to prevent the development of an infectious process, the victim is given antibacterial agents and hormones.

Hemodynamic parameters can be resumed with the help of intravenous infusion of plasma preparations, colloidal solutions, nootropics.

In case of traumatic damage to the pericardium, the patient undergoes surgery in the form of pericardiotomy or subtotal percardioectomy.

Surgical treatment of tamponade is an operational method of eliminating the problem and is carried out exclusively under general anesthesia. Pericardiotomy implies a specific technique for drainage of the cavity of the affected pericardium, followed by revision of the space and removal of the causative foci.

Subtotal pericardiectomy is a radical operation by which surgeons resume the normal functioning of the heart muscle by removing scars, calcifications or malignant neoplasms on the pericardium.

Prevention of tamponade is carried out by performing the following measures:

  • timely diagnosis and adequate treatment of chronic conditions, which can cause the development of hemopericarditis and tamponade;
  • strict adherence to the protocol of minimally invasive diagnostic measures and compliance with all asepsis rules;
  • control of hemodynamic indicators of blood status with prolonged use of drugs from the group of anticoagulants;
  • prevention of chest injuries;
  • periodic preventive examinations by a specialist for patients who are at risk for the development of cardiac tamponade.

Doctors warn that untimely seeking medical help with cardiac tamponade will necessarily lead to death. Only early diagnosis of a pathological condition and qualified treatment in a hospital will allow specialists to save the life of such a patient.

If the treatment was timely, and the pathological process did not manage to be complicated by acute heart failure with cardiac arrest, then, according to statistical studies, almost 80% of patients after all therapeutic measures are successfully discharged from the hospital and continue to lead a normal lifestyle.

Naturally, after discharge from the hospital, such people are strictly forbidden to give the heart muscle to intense physical activity, a special diet and supervision by a cardiologist are recommended.

This condition leads to the fact that the functional activity of this organ is inhibited, as a result of which the process of blood movement through the vessels is disturbed.

In the event that this pathology was not diagnosed in a timely manner, there is a high probability of death due to the development of acute heart failure.

In the usual state in the pericardial cavity is from twenty to forty milliliters of fluid. It is designed to reduce friction as the heart contracts. The development of tamponade is based on an increase in the volume of this fluid due to the influence of any adverse factors on the body.

Most often, the onset of this disease is due to open and closed injuries in the chest area, due to which bleeding occurs in the pericardial cavity. This condition is called hemipericardium.

In addition, various medical manipulations and surgical interventions on the heart, stratified aortic aneurysm, myocardial infarction, which led to rupture of the heart muscle, as well as prolonged use of drugs that reduce blood coagulation can lead to the development of tamponade.

This pathological process is often triggered by prolonged inflammation of the pericardium, malignant neoplasms, inhibition of the functional activity of the kidneys, tuberculosis, systemic lupus erythematosus and many other conditions.

In another situation, namely, with a sudden and sharp accumulation of fluid between the visceral and parietal leaves, intrapericardial pressure can rapidly increase. All this leads to the fact that the heart is compressed and can not be reduced. As a result, the blood stops moving fully through the vessels, due to which other internal organs also suffer.

There are two main varieties of cardiac tamponade: acute and chronic. The most dangerous in terms of prognosis is precisely acute tamponade.

It is accompanied by a rapidly growing clinical picture, which has an unpredictable course. Chronic tamponade is established just in case the fluid accumulates gradually.

Due to this, the accompanying manifestations are much more moderate.

Symptoms in this pathological process are not specific. A sick person often confuses them with other cardiac pathologies and tries to cope with the violation on his own. In this regard, time may be missed, which greatly increases the likelihood of death.

With such a disease, the patient may complain of a feeling of heaviness in the chest, sudden weakness and severe anxiety. As a rule, rapidly increasing shortness of breath is present. The skin becomes pale, cyanotic and covered with sticky and cold sweat.

During the examination, symptoms such as increased heart rate, a violation of their rhythm, as well as a decrease in blood pressure are detected. Attention is drawn to such a moment that breathing has become frequent and superficial.

Blockade by fluid

3
Causes of Cardiac Tamponade

  1. Heart rupture and bleeding in the pericardial cavity. The causes of rupture of the heart muscle or rupture of the myocardium are a complication of myocardial infarction, in which both internal ruptures of the papillary muscle or papillary muscle, interventricular septum, and external ruptures of muscle tissue can be observed. Heart attack is the most common cause. Other causes of heart rupture include penetrating heart wound, aortic rupture, tumor invasion into the cardiac cavity with rupture and bleeding, arteries inside the pericardial can rupture. A condition in which blood accumulates in the pericardial cavity is called hemotamponade.
  2. Exudative pericarditis, not necessarily blood accumulates in the pericardial cavity, lymph, pus, exudate can accumulate.
  3. Profuse bleeding in a heart bag with hemorrhagic diathesis, an overdose of anticoagulants – drugs that make blood liquid.
  4. Bleeding after surgery on the heart.

What are these symptoms indicating that the heart muscle is constricted?

Different types of breaks

Treatment methods, emergency care for tamponade

Because of the threat to the patient’s life, the treatment of cardiac tamponade consists in the urgent evacuation of the accumulated fluid from the pericardial membrane. Do this by puncture or perform an operation with an opening of the chest. To restore hemodynamics, infusion therapy is prescribed using drugs of a number of nootropics or plasma, as well as treatment of the underlying disease.

Pericardial puncture is carried out strictly under radiographic control or using echocardiography. In this case, constant monitoring of arterial and intracardiac pressure is required, as well as monitoring of heart rate. A positive effect is recorded during the evacuation of even 30-40 ml. After the complete elimination of fluid, antibiotics are often injected into the pericardial cavity to reduce the inflammatory process or hormonal medications. To avoid re-accumulation of effusion, a drainage tube is inserted into the pericardium.

With a high risk of developing repeated hemotamps, the patient is prescribed surgery. During the operation, a hole is made in the pericardial cavity through which the accumulated fluid is removed and its internal walls are inspected. This procedure helps to identify the presence of structural pathologies in the heart membrane: neoplasms, injuries, and more.

Since most cases of cardiac tamponade are associated with injuries, you need to know how to provide first aid in such a situation. For chest fractures, a circular bandage bandage must be applied to fix the broken ribs. After this, the presence of dull tones that accompany tamponade is determined by tapping (percussion). With pneumothorax, a sterile dressing is necessary on the wound, which prevents contact with the external environment and is completely tight.

After rendering first aid, the patient must be immediately taken to a medical institution, where pericardial puncture will be performed under the control of the equipment. In some cases, manipulation can be performed by an experienced physician before starting transportation.

Cardiac tamponade can only be resolved surgically: under the control of an ultrasound transducer, pericardial puncture (pericardiocentesis) is performed and fluid is pumped out. This is necessary to ensure the normal functioning of the heart muscle and save the patient’s life. Often you have to leave drainage in the pericardial cavity until the underlying disease is corrected – the causes of effusion.

Pericardial puncture – the very first emergency action in case of cardiac tamponade

In the case of a relapsing course, an open operation is performed in which a part of the heart sac is excised or completely removed.

The accumulation of blood in the pericardium is a condition requiring emergency surgery to eliminate the cause of bleeding.
If this is not done, heart failure quickly sets in.

Surgical treatment is performed on an open heart, depending on the cause of the hemopericardium may include:

  1. Suturing a heart muscle defect.
  2. Removing part of the aorta and replacing the damaged part with a graft.

Often, before the operation itself, it is necessary to perform a pericardial puncture and pump out part of the blood so that during cardiac anesthesia there is no cardiac arrest. It is enough to remove 20-30 ml of contents to improve the functioning of the heart.

A complete cure for heart hemotamponade directly depends on the cause of the accumulation of blood: extensive injuries, an operation not performed at the right time, the technical impossibility of carrying out the full volume of the operation – the causes of death.

Chernysheva Larisa edited by the doctor of the first category Z. Nelli Vladimirovna

Cardiac tamponade is a pathology of its hemodynamics, in which there is an accumulation of fluid in the pericardial cavity, that is, between the sheets of the pericardium (the outer membrane of the heart from the connective tissue) and the epicardium. For example, tamponade of the heart with blood can form due to bleeding in the heart bag with open and closed chest injuries or as a result of invasive and minimally invasive procedures on the heart.

Compression of the heart cavities and increased intrapericardial pressure lead to difficulty in normal heart contractions, impaired diastolic filling of the ventricles and a significant decrease in cardiac output. As a result, cardiac tamponade can cause acute heart failure, a shock state and complete cessation of cardiac activity.

The normal volume of fluid in the heart bag does not exceed 20-40 ml. The condition in which the liquid volume reaches 250 ml may already be critical.

Sometimes this volume reaches even 1000 ml or more: this is possible if the effusion increases gradually and the heart bag has time to stretch, thus adapting to the growing volume of exudate.

These clinical manifestations are characteristic of the chronic form of tamponade.

Acute cardiac tamponade progresses rapidly, and its course is unpredictable. So, in case of violation of the integrity of the aorta or heart muscle, the patient can suddenly lose consciousness and fall into hemorrhagic collapse, in which urgent surgical operation is necessary – in order to avoid death.

4
clinical picture

Dyspnea, sharp increasing general weakness

The clinic for patients with cardiac tamponade is very characteristic. An experienced doctor can diagnose tamponade even without instrumental studies. Symptoms of heart tamponade are as follows:

  1. Increasing shortness of breath
  2. Fear of death
  3. Palpitations
  4. Dizziness, possibly loss of consciousness in acute tamponade,
  5. A sharp increasing general weakness, even weak physical exertion for the patient, is impossible
  6. Severe pain in the heart region of a pressing nature,
  7. Cough,
  8. Hoarseness
  9. Inability to swallow – dysphagia.

Coughing with tamponade of the heart is the result of compression of the trachea, hoarseness occurs when infringement of the recurrent nerve occurs, and with compression of the esophagus, dysphagia is observed. These symptoms are characteristic when the effusion is very significant. The above symptoms are characteristic of a rapidly developing, acute cardiac tamponade.

  1. Pain in the right hypochondrium;
  2. Nausea, periodically vomiting;
  3. An increase in the volume of the abdomen and swelling of the lower extremities.

Etiology

The causes of cardiac tamponade can be:

  • tuberculosis
  • (viral or idiopathic)
  • radiation exposure
  • malignancy
  • systemic diseases of the connective tissue (SLE, rheumatoid arthritis)
  • injury
  • postpericardotomy syndrome

Each disease that affects the pericardium can lead to the accumulation of fluid in its cavity. Acute cardiac tamponade may occur due to trauma, including iatrogenic when installing EX, rupture of the aorta when the aneurysm is stratified, rupture of the heart with myocardial infarction (MI). Subacute cardiac tamponade, as a rule, appears as a result of pericarditis (idiopathic or viral), with uremia or a tumor in the pericardium. In most cases, doctors can not calculate the cause of exudative pericarditis, even when the operation is performed.

Tamponade can develop with any etiology of pericardial effusion. In acute pericarditis, tamponade is more common in neoplastic diseases, tuberculosis and purulent pericarditis, but due to the greater prevalence of idiopathic pericarditis in absolute terms, acute idiopathic pericarditis is considered the main cause of tamponade in patients without underlying disease.

7 How to help the patient?

Patients with tamponade of the heart take a position in which they feel relieved: they often sit, leaning forward, sometimes kneeling, resting their forehead on the pillow. Their skin is pale, with a gray tint, often covered with cold sweat. Neck, face can swell, covered with sticky sweat. The pulse is barely felt, the pressure drops sharply.

Upon examination of the border, the cardiac expand sharply, the heart beat disappears, the heart sounds are extremely deaf, the frequency of contractions rolls over. This indicates the extremely dangerous condition of the patient, the development of an acute, critical condition, the patient immediately needs emergency medical care. If cardiac tamponade develops gradually, enlargement and soreness of the liver, ascites are determined.

First of all, calling for emergency medical care. If a person became ill at home, there were complaints, characteristic of cardiac tamponade, you should not give him the first medicines that came to his hand: nitroglycerin and others. They can further lower blood pressure and worsen the condition of the patient. After examination, the doctors, having determined the indications, perform a pericardial puncture – they insert the needle into a specific point on the chest and pump out the fluid.

The puncture is carried out under the supervision of ultrasound or x-ray control. But this is a temporary measure to alleviate the condition of the patient. It is necessary to identify the cause that led to tamponade and eliminate it: surgically or treating the underlying disease. Success in the treatment of cardiac tamponade is considered to be the elimination of the cause that caused it, and well-being, stabilization of the patient’s condition.

Appearance of a patient with cardiac tamponade

Emergency therapy for tamponade

The puncture is carried out under the supervision of ultrasound or x-ray control. But this is a temporary measure to alleviate the condition of the patient. It is necessary to identify the cause that led to tamponade and eliminate it: surgically or treating the underlying disease. Success in the treatment of cardiac tamponade is considered to be the elimination of the cause that caused it, and well-being, stabilization of the patient’s condition.

Pathogenesis

Cardiac tamponade develops to a greater extent not because of the excess fluid flow into the pericardium, but because of the high speed of this process. Normally, 20-40 ml of fluid will be contained in the heart bag, and the internal pressure is at the level of 0 mm Hg.

The sudden entry into the pericardial cavity of 100-200 ml of effusion or blood leads to a sharp increase in pressure, it is compared with the final diastolic pressure in the ventricles. As a result, there is a squeezing of the heart chambers and nearby sections of the vena cava. The flow of blood into the ventricles worsens, they are not filled enough during diastole, stroke capacity and cardiac output are reduced.

At the same time, a compensatory mechanism is launched, which consists in increasing the central venous pressure and the frequency of contractions to maintain adequate filling of the chambers.

According to the norm, between the leaves of the pericardium can be from 20 to 50 ml of liquid, which makes it easier to slide relative to each other. This liquid in its electrolyte and protein composition corresponds to blood plasma. If there becomes more than 120 ml of fluid, this increases intrapericardial pressure, reduces cardiac output and provokes arterial hypotension.

Clinical manifestations correlate with the rate of fluid accumulation, its amount, and pericardial features. Symptoms of cardiac tamponade occur if the fluid quickly accumulates, and reaches an amount of 200 ml. If the accumulation rate is slow, then symptoms may not occur, even if the fluid is already 1-2 liters.

Increase in intrapericardial pressure with fluid accumulation up to 5-15 mm Hg considered moderate, and more than this amount – pronounced. Diastolic filling of the ventricle due to increased pressure inside the pericardium is accompanied by an increase in pressure in the chambers of the heart and pulmonary artery, a decrease in stroke volume of the heart and hypertension.

6 Instrumental diagnostics

In the diagnosis, instrumental methods are used to clarify the diagnosis.

  1. ECG. On the cardiogram, you can see a sharp decrease in the amplitude of the teeth, the smoothness of T, the alternation of P, T, QRS;
  2. Echocardiography is used urgently for indications of cardiac tamponade. This method is of great importance in the diagnosis of tamponade. The signs of which are:
    • a decrease in the degree of decay of the inferior vena cava upon inspiration (less than 50%),
    • reduction of the cavities of the lower heart chambers,
    • discrepancy of the leaves of the pericardium;

X-ray cardiac tamponade

So, it is already possible to diagnose cardiac tamponade clinically. The clinic allows you to suspect a diagnosis, which is confirmed by urgent echocardiography, measurement of CVP. If these instrumental diagnostic methods are not available, an ECG is performed.

Complications

Complications and prognosis of cardiac tamponade depend on the cause of the disease. Viral and tuberculous pericarditis are often complicated by cardiac tamponade or end in the development of constrictive pericarditis. The effusion associated with uremia, a tumor, systemic diseases of the connective tissue usually needs specific therapy, much less often – pericardectomy.

Cardiac tamponade occurs when the filling of the ventricles is disturbed as a result of fluid accumulation in the pericardial cavity and increased intrapericardial pressure.

It is characterized by an increase in diastolic pressure in the chambers of the heart, a progressive decrease in their filling and a drop in cardiac output.

Tamponade is considered a dangerous disease, in which there is a high risk of complications. They are divided into acute, appearing at the time of filling the pericardium with fluid, as well as later, arising after some time.

In the acute form of pathology, the likelihood of developing various arrhythmias, heart attack, and premature death is quite high. Later complications include inflammation in the pericardium, impaired cardiac conduction.

Not only the disease itself can lead to a deterioration in the patient’s condition, but also a puncture of the heart sac, which is performed to eliminate fluid. As a result of manipulation, the occurrence of cardiac sclerosis and conduction interruptions of impulses from the ventricles towards the atria may occur.

Definition of tamponade and its form

Cardiac tamponade is an acute syndrome that is directly related to problems in the activity of the heart and hemodynamics (ICD-10 code – I31). It arises as a result of rapid accumulation of fluid and a pressure surge directly inside the pericardium. This condition is accompanied by unpleasant sensations behind the sternum, obvious shortness of breath, sinus tachycardia.

Due to the increase in the volume of effusion, the cardiac cavities are compressed, the intrapericardial pressure rises, which leads to deviations in the contraction of the heart. In addition, the ventricles stop filling normally, and cardiac output drops. As a result of such deviations, a complete stop of cardiac activity is possible.

The standard amount of fluid inside the pericardium should not be more than 20-40 ml. This condition is considered critical if the effusion volume exceeds 250 ml. Cases were recorded when the amount of accumulated liquid increased over 1 liter. This condition is possible if the heart bag is gradually stretched as a result of gradual filling. The heart at the same time adapts to the increased excess volume, and doctors talk about the chronic form of the disease.

Acute cardiac tamponade develops very quickly. The course of this pathology is unpredictable, since the integrity of the aorta and heart muscle may be impaired, the patient loses consciousness, he is diagnosed with hemorrhagic collapse. In this case, an emergency surgical operation is required, which will avoid cardiac arrest.

The listed symptoms are typical for a gradual overflow of the heart bag and compression of the heart. This is the chronic form of the disease. It develops relatively slowly against the background of the underlying disease. Often confused with chronic heart failure. Especially if the signs appeared in an elderly person. An important symptom is the absence of swelling on the legs.

Acute cardiac tamponade develops suddenly, often accompanied by a shock condition. If the condition worsens due to trauma, medical manipulation, then the reason is clear to the doctor. Without eliminating the squeezing factor, treatment cannot be successful and will lead to death.

Some authors suggest highlighting the subacute form of tamponade. It can be detected only with constant monitoring of the course of chronic inflammatory diseases (muscle pain, swollen and painful joints, unclear temperature, causeless shortness of breath).

The classic symptoms of tamponade are:

  • expansion and pulsation of veins on the neck;
  • low blood pressure;
  • deaf heart tones.

This list is called the Beck triad, or “small silent heart.”

Hemodynamics

  • After reaching a certain critical value, even a slight increase in the volume of pericardial effusion leads to a significant increase in intrapericardial pressure, the volume of effusion becomes inversely proportional to cardiac output. This critical value depends on the rate of fluid accumulation and on the compliance of the pericardium. The latter decreases with infiltration, calcification and pericardial fibrosis.
  • An increase in intrapericardial pressure interferes with the expansion of the ventricles and thereby reduces their filling.
  • Cardiac output is initially supported by increased sympathetic tone: tachycardia and peripheral vasoconstriction occur.
  • With severe tamponade, compensatory mechanisms do not work and cardiac output decreases. A decrease in coronary blood flow can lead to subendocardial ischemia, which leads to a violation of myocardial contractility and a further decrease in cardiac output. The inability of the pericardial cavity to stretch leads to the fact that the end-diastolic pressure in the ventricles becomes equal to intrapericardial.
  • After heart surgery, the filling of the ventricles may not suffer due to effusion, but because of a hematoma. Hematomas are most often located in the right atrium and are often not diagnosed. With transthoracic echocardiography, unlike transesophageal hematoma, it can be difficult to detect.

Features of hemotamponade

The heart has a special protective shell, which protects the organ from overstretching, displacement during physical exertion. In appearance, it resembles a bag and is called a pericardium. Inside the shell, normally there is always a little special fluid that acts as a lubricant. If an increased amount of effusion is recorded in the heart membrane, they talk about cardiac tamponade, which requires special diagnosis and emergency care.

Of great importance in hemodynamics is the rate of moisture accumulation in the pericardium, as well as the degree of its extensibility. A small amount of fluid (up to 50 ml) in the pericardial bag cannot be diagnosed. But with its further accumulation, deviations can be detected on echocardiography, x-rays and using other research methods. The treatment of pathology should be started immediately, since such conditions often lead to complete.

Echocardiography with cardiac muscle tamponade

Symptoms of the disease

There are situations when tamponade does not appear in any way. In this situation, the course of the disease can be complicated by pericarditis – inflammation of the heart membrane. Therefore, if there are even several of these symptoms, you must consult a doctor for examination.

Prevention

Preventive measures for cardiac tamponade include the implementation of clinical recommendations:

  1. It is necessary to timely diagnose chronic cardiac pathologies, as a result of which tamponade and hemopericarditis may develop.
  2. When conducting minimally invasive research methods, strict adherence to the rules of antiseptics, as well as the procedure algorithm, is required.
  3. During prolonged use of anticoagulants, monitoring of hemodynamic blood parameters is necessary.
  4. Chest injuries should be avoided.
  5. Patients at risk should regularly undergo preventive examinations by a cardiologist.

After discharge from the hospital, it is strictly forbidden to expose the heart muscles to serious stress. After eliminating tamponade, patients need a special diet and regular monitoring by a cardiologist.

Still have questions? Ask them in the comments! A cardiologist will answer them.

Cardiac tamponade occurs due to accumulation in the pericardial cavity (cardiac sac) of a fluid of various origins – blood, pus, lymph, effusion (exudate or transudate). This condition may be the result of direct damage or a complication of chronic diseases.

The main causes of cardiac tamponade:

  • hemopericardium – bleeding into the pericardial cavity with chest injuries;
  • hemorrhage as a result of medical manipulations (myocardial biopsy, venous catheter placement, probing, surgery);
  • myocardial infarction with rupture of the heart;
  • anticoagulant treatment;
  • hemodialysis for chronic renal failure;
  • tuberculous, acute idiopathic or purulent pericarditis (inflammation of the pericardium);
  • malignant tumors in the heart and lungs;
  • lupus erythematosus and other pathologies.

Basic measures for the prevention of tamponade:

  • treatment of pericarditis;
  • rational use of anticoagulants;
  • compliance with the rules for invasive cardiological procedures.

Cardiac tamponade is a difficult pathological process, which consists in compressing the myocardium from the outside and stopping the contractions. Most often seen as a complication of pericarditis as a result of trauma. The condition is life-threatening and requires urgent intervention, without it the patient dies.

Clinical manifestations

Symptoms of cardiac tamponade appear with a significant drop in heart rate and blood flow. Pronounced venous congestion is manifested by the accumulation of blood in the channel of the hollow and hepatic veins. In the acute form, all signs appear quickly, the severity of the patient’s condition increases with every minute.

The most characteristic patient complaints are:

  • sharp weakness;
  • pain in the heart;
  • severe shortness of breath;
  • restlessness, anxiety;
  • less commonly, difficulty swallowing.

Upon examination, the doctor finds:

  • pallor of the skin, blueness of the lips and fingers;
  • cold, sticky sweat;
  • hypotension;
  • pulsating and swollen cervical veins indicate increased venous pressure;
  • palpation revealed an increase in the liver, its painful edge, fluid accumulation in the peritoneum;
  • heart sounds are very deaf, severe tachycardia, arrhythmia;
  • with pericarditis, pericardial friction noise is possible;
  • the symptom of “paradoxical pulse” is a significant decrease or complete disappearance of the pulse on the radial artery during inhalation, the appearance on the exhale.

On a x-ray, the spherical shape of the heart shadow is determined

Patients with a tamponade clinic complain of chest discomfort or typical pericardial chest pain if the cause is acute inflammatory pericarditis, as well as shortness of breath on exertion and at rest and tachypnea. Acute cardiac tamponade as a manifestation of rupture of the aorta and the free wall of the ventricle can manifest with fainting or sudden collapse.

For a non-invasive assessment of the paradoxical pulse, the cuff is inflated by 10-15 mmHg. higher than the highest values ​​of systolic blood pressure and slowly descends to listen to the first strokes. The cuff is pulled down until all bumps are heard. The difference between these two points corresponds to a paradoxical pulse. During inspiration, the filling of the right chambers of the heart increases with a subsequent increase in intrapericardial pressure, which leads to a leftward shift of the atrial and interventricular septa that impede the filling of the left ventricle.

The paradoxical pulse is not a pathognomonic sign of tamponade, as it occurs in COPD, an acute attack of bronchial asthma, narrowing of the trachea, severe pulmonary embolism, or MI. On the other hand, it may be absent in patients with severe hypotension, local compression of the heart after surgery, severe aortic regurgitation, or ASD.

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Svetlana Borszavich

General practitioner, cardiologist, with active work in therapy, gastroenterology, cardiology, rheumatology, immunology with allergology.
Fluent in general clinical methods for the diagnosis and treatment of heart disease, as well as electrocardiography, echocardiography, monitoring of cholera on an ECG and daily monitoring of blood pressure.
The treatment complex developed by the author significantly helps with cerebrovascular injuries and metabolic disorders in the brain and vascular diseases: hypertension and complications caused by diabetes.
The author is a member of the European Society of Therapists, a regular participant in scientific conferences and congresses in the field of cardiology and general medicine. She has repeatedly participated in a research program at a private university in Japan in the field of reconstructive medicine.

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