Cardiac tamponade

Under a cardiac tamponade or pericardial tamponade is defined as the complication of fluid accumulation (see tamponade ) in the pericardium, a so-called pericardial effusion, or the rare complication of an accumulation of air in the pericardium, a so-called Pneumoperikards. Even small amounts of liquid can thus lead to an obstruction of the ventricular filling, a reduced stroke volume and a life-threatening malfunction of the heart. In addition, the blood flow is reduced in the coronary arteries and the heart muscle only with insufficient oxygen supply (hypoxia). Congestive heart failure occurs. The fluid may be blood ( hemopericardium ), serous fluid ( hydropericardium ), pus ( Pyoperikard ) or chyle ( Chyloperikard ) act. The core is compressed from the outside and thus hindered in its function. Especially the diastolic filling of the heart is compromised thereby.

Pathogenesis

Between the epicardium and pericardium pericardium in with 20-50 ml of liquid lubricant ( CSF pericardii ) is gap filled space that surrounds the heart and ensures low-friction movement of the heart muscle in contraction and relaxation. Because the pericardium has no way to expansion due to its very low elasticity, it comes with a fast fluid propagation in this gap to a compression of the heart, as a result, it can no longer be adequately fill with blood, and consequently unable to pump: It comes to a pump failure.

In a rapid accumulation of fluid in the pericardium range 150-200 ml for a tamponade from (eg hemorrhage ), while a slow accumulation of 1000-2000 ml for a tamponade are necessary because the pericardium can stretch slowly.

Causes

  • Trauma Stab or gunshot wound, blunt chest trauma
  • Rupture of coronary artery
  • Extensive myocardial injury, cardiac rupture
  • Lesions of the lung and pleura (Voltage) Pneumopericardium V.A. with pneumothorax li. or bds and PEEP
  • Bleeding, effusion after surgery
  • Myokardperforation at CVC investment in premature and newborn
  • CVC malposition left internal jugular vein in left jugular pericardiophrenica
  • Perforation during PTCA or by pacing lead

Symptoms

The main symptoms of cardiac tamponade are made up of an upper cava with congested neck veins (not with hypovolemia ), the Beck's triad, including a decreased arterial and increased venous blood pressure (hypotension ) and low heart sounds include a shortness of breath (dyspnea ), a reflex, rapid heart rate (tachycardia ), a pulsus paradoxus to a cardiogenic shock with a cardiovascular arrest together. Other symptoms include air hunger, tachypnea, a stagnant urine, a feeling of oppression, sweating, cold extremities, dizziness, restlessness and acute heart failure with a "low- cardiac - output".

Diagnostics

  • Inspection: increased Jugularvenenfüllung, paleness, cold sweats
  • Auscultation: quiet heart sounds, tachycardia
  • Palpation: apex beat hardly / not palpable pulsus paradoxus ( decrease of systolic BD > 10 mmHg with inspiration)
  • ECG: low voltage, electrical alternans, if necessary, ST segment and T wave changes
  • Echocardiography: detection, localization, extent of pericardial effusion
  • Chest x-ray: widening of the cardiac silhouette and the upper mediastinum, bocksbeutel shape of the heart
  • CT, MRI: pericardial effusion or tamponade - displayed well and detectable way too expensive for critically ill patients

The method of choice and a safe and rapid method for diagnosis is echocardiography. There is usually not a lot of time in the presence of cardiac tamponade. The heart must be unloaded first.

Therapy

  • Symptomatic: hemodynamic stabilization, transfer to an intensive care
  • Avoidance of bradycardia
  • Avoidance of PEEP, if possible
  • Causally (decompression): Relief by pericardiocentesis, so removing the fluid from the pericardial sac under ultrasound guidance; with clotted blood, however, can not be tapped in
  • Perikardfensterung
  • Pericardiotomy ( opening of the pericardium ) with a pericardial drainage system or partial pericardiectomy ( removal of the pericardium )
  • Thoracotomy ( opening the chest ) with a pericardial drainage system and partial or complete pericardiectomy
  • In postoperative cardiac surgery patients (eg after valve or coronary bypass surgery) is often a retrosternal drain available, which can be angelupft in the acute situation, possibly with a vacuum cleaner or relieved.
Diastole Central venous catheter Vasculitis Aortic dissection
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