Assessment

HISTORY. The patient's history may include surgery, trauma, cardiac biopsy, viral infection, insertion of a transvenous pacing wire or catheter, or myocardial infarction. Elicit a medication history to determine if the patient is taking anticoagulants or any medication that could cause tamponade as a drug reaction (procainamide, hydralazine, minoxidil, isoniazid, penicillin, methysergide, or daunorubicin). Ask if the patient has renal failure, which can lead to pericarditis and bleeding. Cardiac tamponade may be acute or accumulate over time, as in the case of myxedema, collagen diseases, and neoplasm. The patient may have a history of dyspnea and chest pain that ranges from mild to severe and increases on inspiration. There may be no symptoms at all before severe hemodynamic compromise.

PHYSICAL EXAMINATION. The patient who has acute, rapid bleeding with cardiac tamponade appears critically ill and in shock. Assess airway, breathing, and circulation, and intervene simultaneously. The patient is acutely hypovolemic (because of blood loss into the pericar-dial sac) and in cardiogenic shock and should be assessed and treated for those conditions as an emergency situation.

If the patient is more stable, when you auscultate the heart, you may hear a pericardial friction rub as a result of the two inflamed layers of the pericardium rubbing against each other. The heart sounds may be muffled because of the accumulation of fluid around the heart. If a central venous or pulmonary artery catheter is present, the right atrial mean pressure (RAP) rises to >12 mm Hg, and the pulmonary capillary wedge pressure equalizes with the RAP. Systolic blood pressure decreases as the pressure on the ventricles reduces diastolic filling and cardiac output. Pulsus paradoxus (>10 mm Hg fall in systolic blood pressure during inspiration) is an important finding in cardiac tamponade and is probably related to blood pooling in the pulmonary veins during inspiration. Other signs that may be present are related to the decreased cardiac output and poor tissue perfusion. Confusion and agitation, cyanosis, tachycardia, and decreased urine output may all occur as cardiac output is compromised and tissue perfusion becomes impaired.

Assessment of cardiovascular function should be performed hourly; check mental status, skin color, temperature and moisture, capillary refill, heart sounds, heart rate, arterial blood pressure, and jugular venous distension. Maintain the patient on continuous cardiac monitoring, and monitor for ST- and T-wave changes.

PSYCHOSOCIAL. Acute cardiac tamponade can be sudden, unexpected, and life-threatening, causing the patient to experience fear and anxiety. Assess the patient's degree of fear and anxiety, as well as her or his ability to cope with a sudden illness and threat to self. The patient's family or significant other(s) should be included in the assessment and plan of care. Half of all patients with traumatic injuries have either alcohol or other drugs present in their systems at the time of injury. Ask about the patient's drinking patterns and any substance use and abuse. Assess the risk for withdrawal from alcohol or other drugs during the hospitalization.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Echocardiogram

Normal size, shape, position, thickness, and movement of structures

Echo-free zone anterior to right ventricular wall and posterior to the left ventricular wall; there may also be a decrease in right ventricular chamber size and a right-to-left septal shift during inspiration

Records echoes created by deflection of short pulses of ultrasonic beam off cardiac structures; may also be done as a transesophageal procedure with transmitter inserted into esophagus (transesophageal echocardiogram, or TEE)

Other Tests: Prolonged coagulation studies and/or a decreased hemoglobin and hematocrit if the patient has lost sufficient blood into the pericardium. Electrocardiogram (ECG) and chest x-ray.

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