Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA

The heart lies within the pericardium, a relatively inelastic fibrous sac. The pericardium has some compliance to stretch when fluid is slowly introduced into the pericardial space. However, rapid accumulation overwhelms pericardial ability to accommodate extra fluid. Once a critical volume is reached, intrapericardial pressure increases dramatically, compressing the right ventricle and eventually impeding the volume that enters the left ventricle. When these chambers cannot fill in diastole, stroke volume and cardiac output are diminished, leading to cardiac tamponade, a life-threatening compression of the cardiac chambers by a pericardial effusion. Unless the pressure is relieved by aspiration of pericardial fluid (pericardiocentesis), cardiac arrest is imminent.

Cardiac tamponadeis a critical emergency that can carry high morbidity and mortality. Patients may present in extremis, without much time to make the diagnosis and perform life-saving treatments. Causes of this condition are broken into traumatic and non-traumatic categories, with different treatment algorithms. Stab and gunshot wounds are the primary cause of traumatic tamponade, but it may occur from blunt trauma associated with sternal or rib fractures as well as shearing of vessels from rapid deceleration injuries. Non-traumatic causes include rupture of the aortic base from ascending aortic dissection, myocardial rupture of the ventricle following myocardial infarction, spontaneous bleeding from thrombolytic or anticoagulant medication, and effusions created by infection or cancer.

Slowly growing chronic effusions are usually not life-threatening, even large ones. The pericardium has gradually stretched to incorporate liters of fluid in some cases. These may be treated with elective pericardiocentesis under fluoroscopic guidance, or a pericardial window. However, transition into tamponade physiology with a patient in extremis requires urgent pericardiocentesis, even with a small amount of fluid. Tamponade presents a challenge to diagnose, as its symptoms and physical findings are often nonspecific, common to a number of diseases. An electrocardiogram (ECG or EKG) may show electrical alternans, and a chest xray may show an enlarged "water bottle" cardiac silhouette.

1. Physical exam and preparation for the procedure

1. On reviewing vital signs, make note of tachycardia, hypotension, a narrow pulse pressure, or pulsus paradoxus (paradoxic pulse), which is a decrease in systolic blood pressure more than 12 mmHg during inspiration.
2. Perform a quick general inspection, looking for evidence of critical tamponade. This includes diaphoresis, agitation, distended neck veins, an inability to lie flat, tachypnea, inability to speak full sentences, or cyanosis.
3. Ausc

Tamponade should always rank highly in the diagnoses for undifferentiated shock, particularly in patients with prior cardiac disease, suspected aortic dissection, a history of malignancy, or anticoagulant use. Traumatic tamponade must be considered in both penetrating and blunt trauma scenarios, with temporizing pericardiocentesis performed in deteriorating patients while setting up for thoracotomy. High suspicion, clinical vigilance, understanding of tamponade physiology, and prompt action will help to avoid the deadly