Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

without haemopericardium, trauma, or purulent effusion

1st line – pericardiocentesis

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ACUTE
|
without haemopericardium, trauma, or purulent effusion
1st line – 

pericardiocentesis

In the absence of haemorrhage, trauma, and purulence, patients with cardiac tamponade should be treated with needle pericardiocentesis under echocardiographic or fluoroscopic guidance.[15]​ Pericardiocentesis should be undertaken immediately in patients presenting with sudden haemodynamic collapse and large pericardial effusion. In extreme, life-threatening circumstances where tamponade is known or suspected but imaging guidance is not available, pericardiocentesis should be attempted by experienced operators using anatomical landmarks.​

Pericardiocentesis is contraindicated in aortic dissection and relatively contraindicated in patients with severe coagulopathy.[15]

Major complications include: laceration of the myocardium or coronary arteries, laceration of the liver or abdominal viscera, air embolus, pneumothorax, damage to the phrenic nerve, or arrhythmias.[51][52]​ Such complications occur in 1.5% to 2.0% of cases using echocardiographic guidance and in about 1% of cases using fluoroscopic guidance.[34][53]

Patients must be monitored for pericardial decompression syndrome: a rare, but life-threatening complication of pericardial drainage that results in paradoxical haemodynamic instability and/or pulmonary oedema.[47]

Plus – treatment of underlying cause

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ACUTE
|
without haemopericardium, trauma, or purulent effusion
Plus – 

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

Concomitant management of any identified underlying aetiologies is key.[15]​ Further diagnostic investigation is required in patients without an apparent cause of tamponade.

In patients with cardiac tamponade secondary to non-purulent pericarditis (i.e., viral or idiopathic), treatment with a non-steroidal anti-inflammatory drug (NSAID) and colchicine should be given alongside the intervention.[56] This is to prevent pericardial fluid re-accumulation. Where pericarditis is refractory to medical treatment, or recurs after initial response, the addition of a corticosteroid or interleukin-1 inhibitor should be considered. See Pericarditis​.

2nd line – surgical drainage

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ACUTE
|
without haemopericardium, trauma, or purulent effusion
2nd line – 

surgical drainage

​Immediate surgical drainage may be considered as an alternative option if pericardiocentesis is contraindicated. Pericardiocentesis is contraindicated in aortic dissection and relatively contraindicated in patients with severe coagulopathy.[15]

Although several surgical modalities exist for pericardial drainage, there is a lack of randomised trials comparing outcomes between different techniques. Choice of modality, therefore, depends on the surgeon’s preferred technique and the underlying aetiology.

The traditional surgical approach involves a small subxiphoid incision, direct visualisation of the pericardium, and incising the parietal pericardium. Drainage through video-assisted thoracoscopy with the creation of a pericardial window is another approach that creates a communication between the pleura and the pericardium, allowing the pericardium to decompress.[54]​ One small retrospective study found an association with increased operative time and periprocedural morbidity, but a lower recurrence of effusion and tamponade.[55]​ Balloon pericardiotomy is a percutaneous, minimally invasive approach that has good short-term success rates and a low incidence of recurrent effusion or tamponade.[15]

Patients must be monitored for pericardial decompression syndrome: a rare, but life-threatening complication of pericardial drainage that results in paradoxical haemodynamic instability and/or pulmonary oedema.[47]

Plus – treatment of underlying cause

Back
ACUTE
|
without haemopericardium, trauma, or purulent effusion
Plus – 

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

Concomitant management of any identified underlying aetiologies is key.[15]​ Further diagnostic investigation is required in patients without an apparent cause of tamponade.

In patients with cardiac tamponade secondary to non-purulent pericarditis (i.e., viral or idiopathic), treatment with a NSAID and colchicine should be given alongside the intervention.[56] This is to prevent pericardial fluid re-accumulation. Where pericarditis is refractory to medical treatment, or recurs after initial response, the addition of a corticosteroid or interleukin-1 inhibitor should be considered. See Pericarditis.​

with haemopericardium, trauma, or purulent effusion

1st line – surgical drainage

Back
ACUTE
|
with haemopericardium, trauma, or purulent effusion
1st line – 

surgical drainage

Surgical drainage is indicated in the management of cardiac tamponade complicated by haemopericardium, trauma, or purulent effusion.[15]

Although several surgical modalities exist for pericardial drainage, there is a lack of randomised trials comparing outcomes between different techniques. Choice of modality, therefore, depends on the surgeon’s preferred technique and the underlying aetiology.

The traditional surgical approach involves a small subxiphoid incision, direct visualisation of the pericardium, and incising the parietal pericardium. Drainage through video-assisted thoracoscopy with the creation of a pericardial window is another approach that creates a communication between the pleura and the pericardium, allowing the pericardium to decompress.[54]​ One small retrospective study found an association with increased operative time and periprocedural morbidity, but a lower recurrence of effusion and tamponade.[55]​ Balloon pericardiotomy is a percutaneous, minimally invasive approach that has good short-term success rates and a low incidence of recurrent effusion or tamponade.[15]

Patients must be monitored for pericardial decompression syndrome: a rare, but life-threatening complication of pericardial drainage that results in paradoxical haemodynamic instability and/or pulmonary oedema.[47]

Plus – treatment of underlying cause

Back
ACUTE
|
with haemopericardium, trauma, or purulent effusion
Plus – 

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

Concomitant management of any identified underlying aetiologies is key.[15] Further diagnostic investigation is required in patients without an apparent cause of tamponade.

Purulent pericarditis is a rare occurrence with the advent of antibiotics, although it is a strong risk factor for tamponade​.[32]​ Where it is suspected, intravenous antibiotic therapy must be started immediately. See Pericarditis.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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