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 hemopericardium, trauma, or purulent effusion

1st line – pericardiocentesis

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

pericardiocentesis

In the absence of hemorrhage, 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 hemodynamic 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 anatomic 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 hemodynamic instability and/or pulmonary edema.[47]

Plus – treatment of underlying cause

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

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

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

In patients with cardiac tamponade secondary to nonpurulent pericarditis (i.e., viral or idiopathic), treatment with a nonsteroidal anti-inflammatory drug (NSAID) and colchicine should be given alongside the intervention.[56]​ This is to prevent pericardial fluid reaccumulation. 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 hemopericardium, 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 randomized trials comparing outcomes between different techniques. Choice of modality, therefore, depends on the surgeon’s preferred technique and the underlying etiology.

The traditional surgical approach involves a small subxiphoid incision, direct visualization 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 hemodynamic instability and/or pulmonary edema.[47]

Plus – treatment of underlying cause

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

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

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

In patients with cardiac tamponade secondary to nonpurulent 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 reaccumulation. 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 hemopericardium, trauma, or purulent effusion

1st line – surgical drainage

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

surgical drainage

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

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

The traditional surgical approach involves a small subxiphoid incision, direct visualization 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 hemodynamic instability and/or pulmonary edema.[47]

Plus – treatment of underlying cause

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

treatment of underlying cause

Treatment recommended for ALL patients in selected patient group

Concomitant management of any identified underlying etiologies 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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