Tamponade and cardiac arrest

Cardiac arrest associated with tamponade has an exceptionally poor prognosis. In the vast majority of these cases, the tamponade develops acutely or subacutely. It is uncommon for chronic pericardial effusions to cause sudden cardiac arrest since these cases tend to be recognized and managed before circulatory collapse occurs. The leading causes of cardiac tamponade culminating in cardiac arrest include:

• Aortic dissection: The proximal 4-5 cm of the aortic root is covered within the pericardium. Consequently, a proximal dissection can result in hemorrhage within the pericardium.
• Ventricular rupture: A transmural infarction can cause a rupture in the left ventricular free wall.
• Mediastinal trauma: Penetrating injuries to the mediastinum can cause tamponade.
• Post-operative Complications: Post-surgical complications following thoracic procedures can cause tamponade.

Rapid diagnosis of cardiac tamponade is possible via bedside echocardiography. This reveals pericardial fluid, suggesting hemorrhage in the context of cardiac arrest cases. Highly echogenic fluid indicates that the blood has coagulated, making it very challenging to drain using pericardiocentesis.

In cases of cardiac tamponade, conventional chest compressions are ineffective. This is explained by the elevated intrapericardial pressure due to the tamponade. The increased pressure causes compression of the atria and the ventricles (particularly the former). Even small pressure elevations on the right side can compromise venous return to the right ventricle. Therefore, in the presence of a tamponade, chest compressions have limited efficacy. Furthermore, administering large tidal volumes might inadvertently elevate intrathoracic pressures, additionally compromising venous return. Draining the pericardium, therefore, takes precedence over compressions.

For traumatic tamponades, thoracotomy remains the primary therapeutic intervention. Ideally, it should be performed within 15 minutes of the onset of collapse.

Pericardiocentesis, performed using a large needle introduced either via the subxiphoid or apical window, is generally considered less effective than thoracotomy. This is because it does not ensure complete drainage of the pericardium, and needles or catheters are at risk of bending or damage during chest compressions.

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