Cardiac Tamponade in Children

We have discussed, previously, how the unique anatomic and physiologic differences kids have may make conditions more subtle and challenging to detect and diagnose. Additionally, the rarity of some dangerous conditions makes it difficult to easily consider these conditions. One life-threatening condition that we need to remain vigilant for that is an example of both of these traits is Cardiac Tamponade. Let’s take a minute to digest a Morsel on Cardiac Tamponade in Children:

Cardiac Tamponade: Basics

  • Cardiac tamponade occurs when pericardial fluid accumulates to the point that it restricts cardiac filling and function.
  • Cardiac tamponade is rare in children, but can occur at any age, including neonates. [Haponiuk, 2015]
  • Pediatric Anatomy and Physiology Matter!
    • Pediatric patients are less able to augment cardiac contractility and tolerate pericardial fluid accumulation worse than adults. [Haponiuk, 2015]
    • CO=HRxSV; Cardiac Output is dependent upon Heart Rate (which kids already have nearly maxed out) and Stroke Volume.
    • Pericardial fluid can greatly impact and reduce the pediatric patient’s Stroke Volume. [Haponiuk, 2015]
      • Compression of the atria restricts diastolic filling.
      • Compression of the ventricles reduces end-diastolic volume.
      • Both reduce stroke volume and can also impair coronary perfusion.
  • Tamponade can present after:
    • ACUTE fluid accumulation
    • CHRONIC fluid accumulation
  • BECK’S TRIAD
    • In 1935, Dr. Claude Beck described 2 presenting sets of exam findings for pericardial tamponade. [Jacob, 2009]
      • ACUTE Tamponade Triad
        • Hypotension
        • Venous Distension
        • Diminished Heart Sounds
      • CHRONIC Cardiac Compression Triad
        • High Venous Pressure
        • Ascites
        • Diminished Heart Sounds
    • No findings are specific to Cardiac Tamponade. [Jacob, 2009]
      • Effusions can silently increase in size until hemodynamic compromise abruptly occurs. [Jacob, 2009]
      • Clinical findings of Beck’s Triad were not found to be reliable (JVD – 54%; hypotension – 28%; diminished heart sounds – 22% of cases). [Rodriguez, 2018;Jacob, 2009]
      • Discerning those findings in very young children can be difficult!
        • Hypotension – develops late in children
        • Venous distention of neck veins – hard to see
        • Diminished heart sounds – hard to hear
  • Other clinical findings include: [Jacob, 2009]
    • ECG changes
      • ex, tachycardia, low voltages, PR depression
      • Abnormal in 69% of tamponade cases [Jacob, 2009]
    • CXR
      • Cardiomegaly/increased cardiac silhouette
      • Abnormal in 81% of tamponade cases [Jacob, 2009]
    • Hepatomegaly
    • Pericardial friction rub
    • Peripheral edema
    • ALTERED MENTAL STATUS [Rodriguez, 2018]
      • Cardiac tamponade has been found to present as acute mental status change.
      • Children may demonstrate altered mental status before overt evidence of circulatory shock.
  • Echo / Bedside Ultrasound is the most useful tool in detecting pericardial fluid and assessing for tamponade. [Rodriguez, 2018]

Cardiac Tamponade: Risk Factors

Due to its rarity, challenging presentation, and significant morbidity/mortality associated with it, a HIGH INDEX OF SUSPICION is required to diagnose Cardiac Tamponade in Children. [Rodriguez, 2018]

  • Risk factors for pericardial effusions include: [Bolin, 2018; Haponiuk, 2015; Jacob, 2009]
    • Acute Trauma (obviously)
    • Presence of indwelling central line [Kayashima, 2015;Weil, 2009]
    • Recent cardio-thoracic surgery/procedure [Haponiuk, 2015]
      • Can occur “early” – in 1st week post-procedure
      • Can also occur “late” – up to 6 months after intervention
    • Malignancy
    • Heart Failure
    • Infection
    • Rheumatic Fever
    • Collagen Vascular Diseases (ex, Lupus)
    • Hypothyroidism
    • Severe Renal Disease / Uremia
    • Coagulopathy
  • Pediatric patients with any central line or one of these conditions who present with acute change in their clinical status (ex, acute respiratory distress, cardiovascular collapse, or change in mental status) warrant consideration of Cardiac Tamponade.

Moral or the Morsel

  • It’s not all about Beck’s Triad. Cardiac tamponade may present without Beck’s Triad, especially in children.
  • Keep DDX Wide with Altered Mental Status! Once again, your ultrasound may help sort through the Ddx of your patient with altered mental status.
  • Central line complications are more than sepsis! While infection is high on the list of potential causes of acute illness, the patient with a central line may also have cardiac tamponade.

References

Arciniegas Rodriguez S, Zitek T, Sterett R, Nelson DG. Occult Pericardial Tamponade Presenting With Altered Mental Status. Pediatr Emerg Care. 2018 May;34(5):e93-e94. PMID: 27741064. [PubMed] [Read by QxMD]
Bolin EH1, Tang X2, Lang SM2, Daily JA2, Collins RT2. Characteristics of Non-postoperative Pediatric Pericardial Effusion: A Multicenter Retrospective Cohort Study from the Pediatric Health Information System (PHIS). Pediatr Cardiol. 2018 Feb;39(2):347-353. PMID: 29086807. [PubMed] [Read by QxMD]
Haponiuk I1, Kwasniak E2, Chojnicki M2, Jaworski R2, Steffens M2, Sendrowska A2, Gierat-Haponiuk K3, Leszczyńska K4, Paczkowski K2, Zielinski J5. Minimally invasive transxiphoid approach for management of pediatric cardiac tamponade – one center’s experience. Wideochir Inne Tech Maloinwazyjne. 2015 Apr;10(1):107-14. PMID: 25960801. [PubMed] [Read by QxMD]
Kayashima K1. Factors affecting survival in pediatric cardiac tamponade caused by central venous catheters. J Anesth. 2015 Dec;29(6):944-52. PMID: 26160591. [PubMed] [Read by QxMD]
Weil BR1, Ladd AP, Yoder K. Pericardial effusion and cardiac tamponade associated with central venous catheters in children: an uncommon but serious and treatable condition. J Pediatr Surg. 2010 Aug;45(8):1687-92. PMID: 20713221. [PubMed] [Read by QxMD]
Jacob S1, Sebastian JC, Cherian PK, Abraham A, John SK. Pericardial effusion impending tamponade: a look beyond Beck’s triad. Am J Emerg Med. 2009 Feb;27(2):216-9. PMID: 19371531. [PubMed] [Read by QxMD]
Sanda S1, Newfield RS. A child with pericardial effusion and cardiac tamponade due to previously unrecognized hypothyroidism. J Natl Med Assoc. 2007 Dec;99(12):1411-3. PMID: 18229779. [PubMed] [Read by QxMD]
Thattakkat K1, Zbaeda M. Life-threatening aortic dissection with cardiac tamponade in a healthy 15-year-old male. Pediatr Cardiol. 2006 Sep-Oct;27(5):624-7. PMID: 16944331. [PubMed] [Read by QxMD]
Rhodes M1, Lautz T, Kavanaugh-Mchugh A, Manes B, Calder C, Koyama T, Liske M, Parra D, Frangoul H. Pericardial effusion and cardiac tamponade in pediatric stem cell transplant recipients. Bone Marrow Transplant. 2005 Jul;36(2):139-44. PMID: 15908968. [PubMed] [Read by QxMD]
Truong U1, Moon-Grady AJ, Butani L. Cardiac tamponade in a pediatric renal transplant recipient on sirolimus therapy. Pediatr Transplant. 2005 Aug;9(4):541-4. PMID: 16048611. [PubMed] [Read by QxMD]
van Engelenburg KC1, Festen C. Cardiac tamponade: a rare but life-threatening complication of central venous catheters in children. J Pediatr Surg. 1998 Dec;33(12):1822-4. PMID: 9869062. [PubMed] [Read by QxMD]
Medary I1, Steinherz LJ, Aronson DC, La Quaglia MP. Cardiac tamponade in the pediatric oncology population: treatment by percutaneous catheter drainage. J Pediatr Surg. 1996 Jan;31(1):197-9; discussion 199-200. PMID: 8632279. [PubMed] [Read by QxMD]
Aiuto LT, Stambouly JJ, Boxer RA. Cardiac tamponade in an adolescent female: an unusual manifestation of systemic lupus erythematosus. Clin Pediatr (Phila). 1993 Sep;32(9):566-7. PMID: 8258215. [PubMed] [Read by QxMD]
Kron IL, Rheuban K, Nolan SP. Late cardiac tamponade in children. A lethal complication. Ann Surg. 1984 Feb;199(2):173-5. PMID: 6696533. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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