ICU · cardiovascular

Acute Cardiac Tamponade — Comprehensive ICU Management

Also known as Cardiac tamponade · Pericardial tamponade · Pericardial effusion with tamponade · Beck's triad · Pulsus paradoxus · Electrical alternans · Pericardiocentesis · Pericardial window

Acute cardiac tamponade — compression of the heart by pericardial fluid (or clot/gas) preventing diastolic filling → reduced stroke volume → cardiogenic shock → cardiac arrest. Causes: malignancy (1 — lung, breast, lymphoma, melanoma), idiopathic/viral pericarditis, post-cardiac surgery (clot), uraemia, tuberculosis, aortic dissection (haemopericardium), trauma, post-MI (Dressler syndrome, free wall rupture), radiation, connective tissue disease (SLE, RA), drug-induced (procainamide, hydralazine). Clinical: Beck's triad (hypotension + muffled heart sounds + elevated JVP — classical but uncommon in clinical practice), pulsus paradoxus (10 mmHg drop in SBP during inspiration — from reduced LV filling as RV expands into the compressed pericardial sac), tachycardia, distended neck veins, dyspnoea. ECG: low voltage + electrical alternans (swinging heart in large effusion). Echo: pericardial effusion + RA/RV diastolic collapse + plethoric IVC + respiratory variation in mitral/tricuspid inflow (25% mitral, 40% tricuspid). Management: PERICARDIOCENTESIS (life-saving — aspirate fluid → relieve compression → restore cardiac filling). Echo-guided pericardiocentesis (subxiphoid or apical approach — Seldinger technique with pigtail drain). If recurrent: pericardial window (surgical — subxiphoid pericardiostomy or VATS). Fluid bolus (500 mL crystalloid — increases preload to transiently overcome the pericardial constraint). Avoid positive pressure ventilation (reduces venous return → worsens tamponade). Avoid diuretics/vasodilators (reduce preload → worsen).