emDocs - June 14, 2105 - By Brit Long
"Introduction
The presentation of muffled heart sounds, jugular venous distension (JVD), and hypotension sound familiar? It should as it has been a widely used triad in most textbooks and medical school lectures to describe cardiac tamponade (CT). In reality this triad of findings may only be present in ~40% of patients. Briefly, CT can be categorized into true tamponade (effusion around the heart), constrictive tamponade (due to pericardium not stretching), or a constrictive with effusion (both). Regardless of the cause, the end result of tamponade is compression of the chambers of the heart and impedance of venous return leading to decreased cardiac output. The question then becomes what is the best way to diagnose and treat this condition in the emergency department in the crashing patient? We will review a few case scenarios and discuss management and treatment of this deadly condition...
Discussion
The crashing patient with CT can be both difficult to diagnose and difficult to treat. Pericardiocentesis and thoracotomy are invasive procedures that you should probably not be using if your patient is still awake and talking. In the cases listed above, they are appropriate interventions as both patients will die if an intervention is not pursued. In summary, pericardiocentesis should be performed in any patient with evidence of a pericardial effusion and hemodynamic compromise. ED thoracotomy, while controversial, has absolute indications for the following: penetrating thoracic trauma with previously witnessed cardiac activity and blunt trauma with either witnessed loss of vital signs in the ED (or within 15 minutes) or 1,500 mL out of a chest tube."
http://www.emdocs.net/the-crashing-patient-with-cardiac-tamponade-ed-management/