2. Cardiac Tamponade

📄 Definition

Cardiac tamponade is a life-threatening condition caused by rapid accumulation of fluid in the pericardial sac, compressing the heart and restricting ventricular filling.

🛑 Tamponade is a clinical emergency – urgent recognition and intervention required.

🔥 Causes – Inflammatory Focus (Mnemonic: TAMPONADE)

  • Trauma (blunt or penetrating chest injury)

  • Autoimmune (SLE, RA, Dressler’s syndrome)

  • Malignancy (lung, breast, lymphoma)

  • Pericarditis (viral, bacterial, TB)

  • Overanticoagulation (warfarin, DOACs)

  • Nephrotic syndrome / uraemia

  • Aneurysm rupture (aortic dissection)

  • Drugs (hydralazine, isoniazid)

  • Effusion post cardiac surgery or MI

⚠️ Clinical Features – Beck’s Triad

  • Hypotension

  • Raised JVP

  • Muffled heart sounds

💡 Other signs:

  • Pulsus paradoxus (↓SBP >10 mmHg on inspiration)

  • Tachycardia

  • Dyspnoea

  • Chest discomfort

  • Weak peripheral pulses

Investigations

🥇 First-Line

  • ABCDE assessment

  • ECG: Low voltage QRS, electrical alternans

  • CXR: Enlarged cardiac silhouette (if effusion is large)

  • Bedside Echo (POCUS): Pericardial effusion + right atrial/ventricular diastolic collapse

🥈 Second-Line

  • Formal transthoracic echocardiogram (TTE)

  • Bloods: FBC, U&Es, CRP/ESR, troponin, clotting profile

  • Pericardial fluid analysis: If drained, assess for infection, malignancy, TB

Management – Mnemonic: DRIP

  • Drain: Emergency pericardiocentesis (USS-guided)

  • Replenish volume: IV fluids for preload support

  • Identify and treat underlying cause (e.g. NSAIDs, antibiotics, steroids)

  • Prevent recurrence (e.g. surgical pericardial window if recurrent)

🚨 Do NOT delay drainage for imaging if tamponade is clinically evident.

❗ Complications

  • Obstructive shock

  • Pulseless electrical activity (PEA)

  • Cardiac arrest

  • Recurrence or constrictive pericarditis

PASSMAP Insight
Though rare, cardiac tamponade may present in inflammatory pericarditis (e.g. Dressler’s post-MI, TB pericarditis). Students must know the urgent bedside echo signs and the life-saving need for pericardiocentesis.

🔺 Last updated in line with ESC Guidelines 2021 – Pericardial Diseases
Published: August 2021 • Reviewed: July 2025
✅ PASSMAP ensures all content is clinically aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

🩺 Clinical Scenario

A 45-year-old man presents to A&E with worsening breathlessness and chest discomfort. He has a history of recent viral pericarditis. On examination, he is tachycardic (HR 122 bpm), hypotensive (BP 88/60 mmHg), and has distended neck veins. Heart sounds are muffled. ECG shows low voltage QRS complexes. Bedside echocardiogram reveals a large pericardial effusion with diastolic collapse of the right atrium.

❓Question:

What is the most appropriate next step in the management of this patient?

A) Intravenous diuretics
B) Urgent CT thorax
C) High-dose ibuprofen and colchicine
D) Intravenous thrombolysis
E) Emergency pericardiocentesis

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🧠 Explanation:

This patient is displaying classical signs of cardiac tamponade, a life-threatening emergency. Features include:

  • Beck’s Triad: hypotension, muffled heart sounds, raised JVP

  • Pulsus paradoxus (noted in practice)

  • ECG: low voltage QRS and possibly electrical alternans

  • Echo: pericardial effusion with right-sided diastolic collapse

Pericardiocentesis is the definitive treatment – it relieves pressure on the heart and restores cardiac output.

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