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