Oncologic Emergencies: Pericardial Effusion and Cardiac Tamponade

Cardiac tamponade is the accumulation of fluid in the pericardial space. The accumulation compresses the heart thus, impedes the expansion of the ventricles and cardiac filling during diastole. As ventricular volume and cardiac output fall, the heart pump fails and circulatory collapse and failure develops. With gradual onset, fluid accumulates steadily and the outer layer of the pericardial space stretches to compensate for the rising pressure. Large amounts of fluid accumulate before symptoms of heart failure occur. With rapid onset, pressures rise too quickly for the pericardial space to compensate. Most common causes of cardiac tamponade include cancerous tumors and cancer treatment. Radiation therapy of 4,000 cGy or more to the mediastinal areas has also been implicated in pericardial fibrosis, pericarditis, and resultant cardiac tamponde. Untreated pericardial effusion and cardiac tamponade lead to circulatory collapse and cardiac arrest.

Manifestations

The following are the presentations of cardiac tamponade and pleural effusion:

1. Neck vein distention during inspiration (Kussmaul’s sign)
2. Pulsus paradoxus (systolic BP decrease exceeding 10mmHg during inspiration; pulse gets stronger on expiration)
3. Narrow pulse pressure
4. Shortness of breath
5. Tachypnea
6. Weakness
7. Chest pain
8. Orthopnea
9. Diaphoresis
10. Distant heart sounds, rubs and gallops, cardiac dullness
11. Compensatory tachycardia
12. Increased venous and vascular pressures
13. Lethargy
14. Altered consciousness from decreased cerebral perfusion
15. Anxiety

Diagnosis

To verify the presence of this malady, the following exams and tests are done:

• ECG helps diagnose pericardial effusion
• Chest x-rays show small amounts of fluid in the pericardium (small effusion), while disclose “water-bottle” heart (large effusion)
• CT scans help diagnose pleural effusions

Management

1. Pericardiocentesis (aspiration or withdrawal of the pericardial fluid by a large-bore needle inserted in the pericardial space)
2. Windows or openings in the pericardium can be created surgically to drain fluid into the pleural space
3. Catheters may also be placed in the pericardial space and sclerosing agents (tetracycline, talc, bleomycin, 5-fluorouracil or thiotepa) injected to prevent fluid reaccumulation
4. Radiation therapy or antineoplastic agents
5. Monitor vital signs and oxygen saturation frequently
6. Assess for pulsus paradoxus
7. Monitor ECG tracings
8. Assess heart and lung sounds, neck vein filling, LOC, respiratory status and skin color and temperature
9. Monitor and record intake and output
10. Review ABG and electrolyte levels
11. Elevate head of bed to ease breathing
12. Minimize patient’s physical activity; administer supplemental oxygen as prescribed
13. Provide frequent oral hygiene
14. Reposition and encourage the patient to cough and take deep breaths every 2 hours
15. As needed, maintain patent IV access, reorient patient and provide supportive measures and appropriate instruction

Byron Webb Romero, RN, MSN

Finished BSN at Lyceum of the Philippines University, and Master of Science in Nursing Major in Adult Health Nursing at the University of the East Ramon Magsaysay Memorial Medical Center. Currently working at Manila Doctors College of Nursing as a Team Leader for Level I and II, Lecturer for Professional Nursing Subjects, and also a Clinical Instructor.

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