 Hi and welcome to nursing school explaining this video on cardiac tamponade, which can be a life-threatening condition. Physiologically, remember that the heart is covered by the pericardium, which is this kind of a layer membrane, and there's pericardial fluid inside the membrane that just allows the heart to kind of float freely in this pericardial sac. Now, a cardiac tamponade occurs when that fluid just becomes extra. So there's a sudden accumulation of this fluid in that pericardial sac, and that can be either blood or some kind of other fluid. Usually, that volume in the pericardial sac is about 10 to 20 milliliters, so very small amount, and even a little bit amount of extra fluid can lead to some serious problems here. So this increase in volume causes compression of the heart, because now it can't escape it. It compresses on the heart itself and the coronary arteries, which then leads to impaired filling and ejectionability of the heart, and therefore we have decreased oxygen supply to the entire body. So it's basically because the layer, the pericardial layer surrounds the heart. If there's fluid, it compresses down on the heart, which then can't expand and contract the way it usually does, which decreases the cardiac output, and then the patient will have certain signs and symptoms that we'll look at in a moment here. So if we look at this graph here, I've drawn a heart with the four chambers, right atrium, left atrium, right ventricle, left ventricle, and then black is just the heart muscle itself. Then in blue, we have the pericardium around the heart, and then red is the pericardial fluid. And on the left side here, this is just a normal anatomy, where when we have what's called the pericardial effusion, which is increased fluid in that pericardial sac, it then compresses the heart muscle up. You can see the heart muscle on that right side here is a lot smaller, but because it can't expand and contract the way it usually does, it causes some serious problems. So in terms of signs and symptoms, let's look at causes first. So causes 50% of pericardial effusions and tamponauts are caused by malignancies in the body, and that can be anything from multiple myeloma or lung cancer, and anything that has spread to the thoracic cavity and then the heart muscle itself. So 50%, half of all cases are because of some sort of cancer related. But it can also be due to renal failure, and then the patient will have uremic pancreatitis, which then can lead to the buildup in the pericardium of that fluid. It can also be a blunt or penetrating trauma. If you think about it in a car accident, if the airbag goes off, for example, there's some blunt trauma to the chest and just a minor vessel ruptures in that sac, and then it bleeds into it. It can you lead to the tamponaut or penetrating, of course it has some sort of penetrating injury to the pericardial sac that then causes bleeding into that cavity. And then also hospital induced really causes can be the discontinuation of pericardial pacing wires. So these are usually some that are used after the patient undergoes a bypass surgery because these are kind of there for the emergency and then eventually they have to be removed. But with the removal of those that pericardial sac can be nicked and causing some bleeding or fluid to accumulate there. But it can also happen with the discontinuation of central lines or after an angiogram as a sort of a complication because the heart muscle has been maneuvered or touched to a certain degree during these procedures. And then lastly here we have infections such as HIV, tuberculosis, rheumatoid arthritis and lupus that can also lead to pericardial tamponaut or cardiac tamponaut. Signs and symptoms here very, very important. It's called Bex Triad and there are three things that will happen. Decreasing blood pressure, muffled heart sounds and JVD. Let's think back about what's happening here. So if the heart muscle can't expand and contract the way it does it only has an ability to squeeze very little, not produce that cardiac output, of course the blood pressure will drop. If the heart muscle here itself and this is not just two dimensional, this is three dimensional is based in this cardiac fluid. If you put your stethoscope on the patient's chest, you're going to be listening through that fluid so the heart sounds will be muffled. And then also because the fluid backs up because the heart can't feel appropriately, it'll cause that back up and you'll see the jugular venous distention here. So these three Bex Triad are the telltale signs for cardiac tamponaut and this is something that often will occur on NCLEX exams, on CLASS exams for critical care as well as your CEN, your certified nursing examination or even your critical care nursing specialty examination. So keep that in mind, Bex Triad. But with this the patient also might exhibit other signs and symptoms that are kind of indicative of shock, which is shortness of breath, so tachypnea or dyspnea, as well as the heart it will go up because the body is trying to compensate for the lack of oxygen. The peripheral pulses will be diminished because the heart cannot produce the cardiac output and blood pressure, therefore the patient's extremities might also turn pale. There might be decreased perfusion to the brain, so the patient may have altered level of consciousness, as well as decreased urinary output because of the decreased renal perfusion. And then skin signs, I put that there just in general for like diaphoretic, pale, cool diaphoretic skin, those kind of signs of shock that we always talk about. In terms of diagnostic tests, an echocardiogram will be a pretty indicative test of the fluid accumulation around the heart. Many times it's done at the bedside. So if this is somebody that comes in after a blunt trauma to the chest or even a penetrating trauma to the chest and there are these signs and symptoms of the Bex Triad, the ER doc will just pull up the bedside echocardiogram, take a quick look and then see that there is an effusion or even a tamponade and then take care of it from there. But if this is something with malignancy, sometimes it can develop a little bit slower. So then other tests are also indicated, which then of course are an EKG to look at the heart, CBC and CMP to take a look at basic labs along with bleeding studies, PT, INR, as well as the chest x-ray or CT of the chest to take a look exactly as to what's going on. And then most certainly you want to consider a troponin to rule out any kind of other acute coronary causes for this, the patient's presentation. This is from cardiac tamponade, dysrhythmias because clearly when the heart muscle is irritated, it can't contract and expand the way it usually does, it can cause dysrhythmias. There can also be infections and that's mostly related to any kind of either penetrating injury or malignancies that can cause infection. It can recur. So if you had a cardiac tamponade before and this due to a malignancy especially, it can definitely recur. But if it's untreated and not taken care of, the heart muscle will continue to get compressed, compressed, compressed and not be able to expand and the patient might die from it. Treatment for this is pericardiocentesis and remember that synthesis always means withdrawal or fluid. So we're going to withdraw that fluid from the pericardiocavity and what that means it's a specialized procedure that mostly the ER doc or the intensivist will be trained for a cardiothoracic surgeon and we want to have the patient sit up at the head of the bed with about 60 degrees to allow for gravity to drain and they will take a big needle catheter and put that right from kind of like the xyfoid process up towards the pericardium towards the heart, get into this pericardiocavity right here with that needle and draw that fluid out which then in turn will allow the heart again to re-expand and contract as normal and hopefully those signs and symptoms of Bextriad will resolve. Certainly we want to have emergency equipment there at the bedside because first of all this is a needle into the pericardium which can cause complications in itself such as the heart muscle can be punctured, maybe the patient is already on the verge of crashing so they might need to be intubated or defibrillated so we want to make sure we have our emergency equipment handy. Sometimes the patient might need an emergency thoracotomy which is basically an open procedure where the chest wall is opened and then manually that pericardium is drained if we can do it with the pericardiocentesis and sometimes especially if it's been recurring or if this is because of a malignancy the fluid might re-accumulate so then they perform what's called a pericardio window which is that drainage catheter that we have inserted into that pericardium will stay in there and drain kind of just like any other catheter and by gravity that fluid will just drain out as it re-accumulates to make sure that the heart can expand and contract the way it's supposed to to maintain patient's blood pressure and heart rate. In terms of nursing care think of your ABCs so we want to have provide the patient with some O2 because we know that we have decreased O2 supply if the heart muscle can pump the way it usually does. We want to have intubation equipment ready at the bedside for what I already covered and we want to make sure we elevate the head of the bed just to facilitate ease of breathing for the patient. In terms of breathing so the B in the ABCs basically the same thing applies and in addition we want to make sure we measure the patient's O2 sat to see where they are and detect any changes. In terms of C for circulation we want to make sure we have a large bore IV and at least two of those accessible because we might have to anticipate administering IV fluids or blood products or vasopressors depending on how critical the patient is and think about if this is a patient who just had a traumatic injury there might be other injuries that we need to manage and be able to administer these medications and products if the need arises. Certainly we want to have the patient on the cardiac monitor and monitor vital signs very frequently because this can be this patient in this shocky state who is very labile with their blood pressure and heart rate. And then last but not least we want to provide emotional support because this is a life-threatening condition cardiac tamponade if that heart muscle continues to compress there is no way out and eventually the heart will just not be able to pump the way it's supposed to so emotional support especially in cancer patients but also in trauma patients is super important not only emotionally supporting the patient but also the loved ones that might be there at the bedside with them. Thank you for watching this video on cardiac tamponade also see my other videos in the critical care and the emergency playlists that will cover many other topics that pertain to critical care situations thanks for watching Nursing School Explained see you soon.