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ONLINE EXCLUSIVE CONTINUING EDUCATION
Cardiovascular Emergencies:
Pericardial Effusion and Cardiac Tamponade
Jo Ann Flounders, MSN, CRNP, OCN, CHPN
ardiac tamponade is a life-threatening emergency that
diac tamponade (Harken et al., 1997; Knoop & Willenberg;
C
Smeltzer & Bare, 1996). Anthracyclines, such as doxorubicin
occurs when excessive fluid in the pericardial space,
or daunomycin, can be responsible for the development of
called a pericardial effusion, creates increased pressure
pericardial effusions (Chabner & Myers, 1993).
in the pericardial sac that compromises the heart's ability to
People with cancer may experience pericardial effusions
fill and pump. Consequently, cardiac output decreases and
and cardiac tamponade caused by nonmalignant conditions,
systemic perfusion is impaired (Dietz & Flaherty, 1993;
although the incidence is less compared to malignant causes.
Hunter, 1998). The distinction between pericardial effusion
Diseases such as rheumatoid arthritis, systemic lupus erythe-
and cardiac tamponade is important. Pericardial effusion is an
matosis, hypoalbuminemia, renal failure, or hypothyroidism
anatomic diagnosis of abnormal pericardial fluid accumula-
may cause increased serous fluid in the pericardial sac or se-
tion that has no hemodynamic consequences, whereas cardiac
tamponade is a physiologic diagnosis of varying amounts of
rous effusion (Bullock, 2000; Lawler, 1999). Infectious peri-
carditis caused by bacteria, fungus, virus, or tuberculosis can
pericardial fluid that causes increased pressure and resultant
cause cardiac tamponade as a result of accumulation of large
hemodynamic consequences (Harken, Hammond, & Ed-
munds, 1997).
volumes of infected fluid. Other cardiovascular conditions,
such as chest trauma, aneurysm, improper insertion of a cen-
Etiology
Although cardiac tamponade can be caused by malignant or
nonmalignant conditions, malignant disease resulting in peri-
Goal for CE Enrollees:
cardial effusion is a major cause of cardiac tamponade in many
patients (Keefe, 2000; Knoop & Willenberg, 1999; Mar-
To further enhance nurses' knowledge of cardiovascular
kiewicz, Borovik, & Ecker, 1986; Pass, 1997). Malignant inva-
emergencies of patients with cancer.
sion of the pericardium or myocardium may be the result of
metastatic tumors or direct extension of a primary tumor (De-
Objectives for CE Enrollees:
Michele & Glick, 2001). Whereas primary tumors of the heart,
On completion of this CE, the participant will be able to
such as mesotheliomas and sarcomas, occur rarely, malignant
1. Describe two cardiovascular emergencies for patients with
invasion of the heart by metastases or direct extension occurs
cancer.
more frequently (Knoop & Willenberg; McAllister, Hall, &
2. Describe medical management of the cardiovascular emer-
Cooley, 1999). Malignancies that cause secondary tumor in-
gencies.
volvement, either by metastasis or local extension, include lung,
3. Discuss nurses' role in the care of patients with cardiovas-
breast, and esophageal cancers. Hodgkin's and non-Hodgkin's
cular emergencies.
lymphomas frequently involve the mediastinum and pericar-
dium. Leukemias can infiltrate the myocardium and cause small
effusions (Keefe; Knoop & Willenberg). Sarcomas, melano-
mas, and liver, gastric, and pancreatic malignancies also can
metastasize to the heart.
Jo Ann Flounders, MSN, CRNP, OCN  , CHPN, is a nurse practitio-
Cancer treatment also may cause pericardial effusion with
ner at Consultants in Medical Oncology and Hematology in Drexel
resultant cardiac tamponade (Knoop & Willenberg, 1999).
Hill, PA.
Radiation therapy of more than 4000 cGy to the mediastinal
Digital Object Identifier: 10.1188/03.ONF.E48-E55
area can cause pericarditis, leading to the development of car-
ONF VOL 30, NO 2, 2003
E48
The severity of cardiac tamponade depends on the amount
tral venous catheter, or complications secondary to angiogra-
of pericardial effusion, the rate of accumulation, and the de-
phy, can cause serosanguinous pericardial effusion and sub-
gree of pericardial compromise (Schafer, 1997). Onset may be
sequent tamonade (Bullock; Schafer, 1997).
gradual or rapid. If fluid accumulates slowly, the parietal peri-
Physiology
cardium is able to stretch to compensate for the increased
pressure and large amounts of fluid may be tolerated without
The heart and segments of the great vessels are sur-
symptoms. However, when fluid accumulates rapidly, the
rounded by the pericardium, a thin, tough fibrous sac with
pericardial pressure rises quickly, compensatory mechanisms
two layers (Knoop & Willenberg, 1999; Maxwell, 1997;
cannot adapt, and severe cardiac tamponade results (Bullock,
Schafer, 1997). The inner layer, called the visceral pericar-
2000; Knoop & Willenberg, 1999; Schafer; Smeltzer & Bare,
dium, is a serous membrane connected to the surface of the
1996).
heart. The outer fibrous membrane of the pericardium is the
The risk of cardiac tamponade for patients with cancer cor-
parietal layer, which provides strength and protection and is
responds to the etiologic factors that cause cardiac tamponade.
in direct contact with the chest wall at the left sternal posi-
Figure 1 presents a summary of patients with cancer who are
tion (Schafer). Between the visceral membrane and the pa-
at risk for cardiac tamponade.
rietal membrane is the pericardial cavity that cushions the
myocardium.
Assessment
The mesothelial cells of the visceral pericardium produce
1050 ml of clear serous lubricating fluid that prevents fric-
Signs and symptoms of cardiac tamponade are related to
the amount and rapidity of onset of pericardial fluid accumu-
tion between the membranes during contraction and relax-
ation of the heart (Mangan, 1992). This pericardial fluid arises
lation and require a careful and thorough history and review
from the lymphatic channels surrounding the heart (Schafer,
of symptoms. Clinical manifestations increase in severity if
1997) and normally is reabsorbed and drained by the lym-
pericardial fluid rapidly accumulates or if a small pericardial
phatic system into the mediastinum and right heart cavities
effusion progresses into a large effusion (Knoop & Wil-
(Uaje, Kahsen, & Parish, 1996).
lenberg, 1999; Mangan, 1992; Schafer, 1997). Therefore,
patients may be initially asymptomatic when pericardial effu-
Pathophysiology
sions are small or develop slowly.
Early symptoms of pericardial effusion with tamponade
Excessive fluid can accumulate in the pericardial sac for a
include
variety of reasons (Beauchamp, 1998). As malignant invasion
1. Dyspnea, which is usually the most common presenting
of the pericardium occurs, the invasive malignancy or the
symptom (Shepherd, 1997)
pericardial tissue itself may produce excess fluid in response
2. Retrosternal chest pain that increases when patients are
to the malignant process (Smeltzer & Bare, 1996). Pericardial
supine and decreases when leaning forward because of
fluid can collect when lymphatic and venous flow is ob-
compression of the heart
structed by tumor, therefore preventing reabsorption of fluid
3. Cough, dysphagia, hoarseness, or hiccups caused by me-
(Mangan, 1992). Invasive tumors also can bleed, and because
chanical compression of nerves of the esophagus, bronchi,
blood accumulates more rapidly than transudates or exudates,
and trachea (Uaje et al., 1996)
these pericardial effusions tend to progress to cardiac tampon-
4. Dizziness, lightheadedness, or agitation caused by hypoxia
ade more rapidly (Keefe, 2000).
5. Weakness, fatigue, and malaise resulting from decreased
Cardiac tamponade results when cardiac function is im-
cardiac output
paired by pressure exerted by pericardial effusion. As pericar-
6. Palpitations
dial fluid increases, the increased pressure in the pericardium
7. Vague gastrointestinal complaints, including anorexia,
compresses all four chambers of the heart (Beauchamp, 1998;
nausea, and vomiting because of visceral congestion and
Bullock, 2000; Knoop & Willenberg, 1999; Mangan, 1992).
venous stasis (Mangan, 1992; Pass, 1993).
The right atrium and right ventricle initially are compressed,
leading to decreased right atrial filling during diastole. As less
venous blood returns to the right atrium, increased venous
pressure results, which is evidenced by jugular vein disten-
tion, edema, hepatomegaly, and increased diastolic pressure.
Patients with malignancies that metastasize to the pericardium, such as
Continued compression of the heart leads to decreased dias-
breast, lung, esophagus, gastrointestinal, and hepatic malignancies; sar-
tolic filling of the ventricles as well, causing decreased stroke
coma; and melanoma
volumes, decreased cardiac output, and poor tissue perfusion.
The body attempts to compensate with cardiac stimulation by
Patients with hematologic malignancies, such as leukemia and lymphoma
the adrenergic nervous system, resulting in tachycardia and
peripheral vasoconstriction. Decreased tissue perfusion causes
Patients with primary tumors of the heart, such as mesothelioma and sar-
activation of the renin-angiotensin-aldosterone system as the
coma
body attempts to increase blood volume and improve stoke
Patients who have been treated with radiation therapy of 4000 cGy or
volume (Bullock). As a result, workload on the failing heart
greater to the mediastinal area
is greatly increased. As these compensatory mechanisms are
exhausted, a cycle of increased fluid, with decreased cardiac
Figure 1. Patients With Cancer at Risk for Development of
output and decreased venous return, will cause circulatory
Cardiac Tamponade
collapse and lead to shock, cardiac arrest, and death if not
corrected (Schafer, 1997).
Note. Based on information from Hunter, 1998; Knoop & Willenberg, 1999.
FLOUNDERS VOL 30, NO 2, 2003
E49
sounds (i.e., the tapping sounds heard during auscultation of
Late symptoms of cardiac tamponade include
a blood pressure) are heard only during expiration. Note the
1. Increasing retrosternal chest pain, causing patients to as-
mmHg when sounds are heard during both inspiration and
sume a forward-leaning position
expiration. Pulsus paradoxus is a difference greater than 10
2. Progressive dyspnea at rest and orthopnea caused by de-
mmHg between the first Kortokoff sound during expiration
creased cardiac output and hypoxia, as well as decreased
and the mmHg when sounds are heard during both inspiration
lung expansion caused by the enlarged mediastinum
and expiration. In patients with cardiac tamponade, sounds are
3. Peripheral edema resulting from venous congestion
heard during expiration alone for a prolonged period of time
4. Confusion, restlessness, or apprehension caused by hy-
(Beauchamp, 1998; Mangan, 1992).
poxia and decreased cerebral perfusion (Beauchamp, 1998;
Hepatojugular reflux is defined as an elevation in jugular
Hunter, 1998; Knoop & Willenberg; Mangan; Schafer
venous pressure by 1 cm or more (Schafer, 1997). Elevate the
1997; Shepherd).
head of the bed to a position at which jugular venous pulsa-
Physical Examination
tions are visible, usually 3045. Exert pressure continuously
over the right upper quadrant of the abdomen for 3060 sec-
Pericardial effusions frequently are not suspected until the
onds while observing the jugular pressure. Increased venous
late signs and symptoms of cardiac tamponade occur. This is
congestion causes an increase in jugular pressure with ab-
primarily a result of the fact that early symptoms may be non-
dominal pressure resulting in positive hepatojugular reflux
specific or falsely attributed to tumor progression. In addition,
(Dietz & Flaherty, 1993; Schafer).
symptoms of increased pericardial effusion and cardiac tam-
In addition to pulsus paradoxus and hepatojugular reflux,
ponade resemble symptoms of pulmonary complications and
other late signs of cardiac tamponade include
often are mistaken for pulmonary or pleural metastasis. Many
1. Resting tachycardia greater than 100 beats per minute
patients with malignant pericardial tamponade also have pleu-
caused by adrenergic stimulation to compensate for re-
ral effusions (i.e., accumulation of fluid in the pleural space
duced cardiac output
between the lung and chest wall), as well as malignant paren-
2. Tachypnea caused by decreased cardiac output, hypoxia,
chymal pulmonary involvement (Beauchamp, 1998; Shep-
and limited expansion of the lung resulting from the en-
herd, 1997). Consequently, diagnosis of pericardial effusion
larged mediastinum
and tamponade is challenging, although imperative, because
3. Hypotension from reduced cardiac output
if not recognized and treated aggressively, the outcome poten-
4. Narrow pulse pressure caused by compression of the heart
tially is fatal.
that, in turn, causes decreased systolic and increased dias-
After consideration of risk factors and review of symptoms
tolic blood pressure
indicative of cardiac tamponade, a physical examination must
5. Pale, ashen, and diaphoretic skin with cool, clammy ex-
be completed. Possible early signs of cardiac tamponade in-
tremities and peripheral cyanosis from reduced cardiac
clude
output, hypoxia, and peripheral vasoconstriction
1. Muffled heart sounds, undetectable or weak apical pulse,
6. Increased central venous pressure, marked jugular venous
or positional pericardial friction rub caused by increased
pressure, ascites, hepatomegaly, and peripheral edema,
pericardial fluid
caused by venous congestion
2. Mild tachycardia of 100 beats per minute caused by com-
7. Oliguria progressing to anuria as a result of decreased re-
pensatory adrenergic stimulation
nal blood flow
3. Mild peripheral edema and abdominal distention as a result
8. Impaired consciousness, progressing to obtundation,
of venous and visceral congestion
caused by decreased cerebral perfusion (Beauchamp,
4. Fever caused by an inflammatory process in the pericar-
1998; Hunter, 1998; Knoop & Willenberg, 1999; Mangan,
dium (Beauchamp, 1998; Bickley, 1999; Hunter, 1998;
1992; Schafer, 1997; Shepherd, 1997).
Mangan, 1992).
As cardiac tamponade progresses, patients will appear criti-
Diagnostic Studies
cally ill. Physical examination may reveal pulsus paradoxus
or hepatojugular reflux, which are possible features of cardiac
Although not diagnostic for cardiac tamponade, a routine
tamponade (Schafer, 1997). Pulsus paradoxus is a decrease or
chest x-ray and electrocardiogram (ECG) may be the initial
absence of the amplitude of the pulse on inspiration (Beau-
tests that identify abnormalities and reveal the need for more
champ, 1998). Normally, a decrease in systolic blood pressure
diagnostic testing (Mangan, 1992). An anterior-posterior chest
occurs with inspiration because breathing causes cyclic
x-ray may demonstrate an enlarged cardiac silhouette result-
cardiocirculatory changes (Knoop & Willenberg, 1999).
ing from the increased amount of fluid in the pericardial sac
However, this mechanism is exaggerated during cardiac tam-
(Lawler, 1999). Chest x-rays in more than half of patients with
ponade because the myocardium is constricted and inspiration
pericardial effusions demonstrate cardiac enlargement, medi-
causes the diaphragm to exert additional pressure on the peri-
astinal widening, or hilar adenopathy (DeMichele & Glick,
cardial sac. The left ventricle receives less blood, causing de-
2001). The heart may develop a water-bottle appearance on
creased stroke volume, decreased cardiac output, and, there-
chest x-ray, with loss of the normal contours of the pericardial
fore, decreased blood pressure during inspiration (Beau-
reflection (Pass, 1993). However, the chest x-ray cannot dif-
champ; Mangan, 1992; Schafer).
ferentiate between possible causes of an enlarged heart shad-
Pulsus paradoxus often is a late sign of cardiac tamponade
ow, and, because of this lack of specificity, the chest x-ray
that can be detected by assessing blood pressure with a sphyg-
does not provide conclusive evidence to support a pericardial
momanometer. Inflate the cuff to 20 mmHg above the normal
effusion (Mangan; Schafer, 1997).
systolic pressure. While slowly deflating the cuff, observe the
The ECG changes often are nonspecific, but may show ta-
patient's respiratory rate and note the mmHg when Kortokoff
chycardia, premature contractions, and electrical alternans
ONF VOL 30, NO 2, 2003
E50
of mechanical factors, such as cirrhosis. An exudate, which is
(i.e., an ECG pattern of alternating amplitude of the P wave
rich in protein, is a fluid that has leaked from blood vessels
and the QRS complex with every other beat, caused by exces-
with increased permeability. Malignant effusions often are
sive heart movement in the increased fluid of the pericardium)
exudates that contain cellular debris resulting from irritation
(DeMichele & Glick, 2001; Knoop & Willenberg, 1999;
of the serous membrane by sloughed cancer cells (Maxwell,
Mangan, 1992). Diffused low voltage (less than 5 mm) in the
1997). Malignant effusions usually are serosanguinous, as
limb leads and precordial leads of an ECG can be an indica-
compared to the clear straw color of normal pericardial fluid
tion of significant pericardial effusion.
(Schafer, 1997). Cytologic examination of the fluid is neces-
The most specific and sensitive noninvasive test for pericar-
sary to determine the etiology of the effusion and determine
dial effusion or cardiac tamponade is the two-dimensional
appropriate medical management.
echocardiogram (2-D echo), which has become the imaging
Pericardial fluid may reaccumulate, therefore a definitive
technique of choice when malignant pericardial effusion is
medical or surgical treatment usually follows pericardio-
suspected (DeMichele & Glick, 2000; Shepherd, 1997). A 2-
centesis to prevent recurrence of cardiac tamponade.
D echo uses painless ultrasound waves to create a picture of
Pericardial sclerosis involves instillation of chemicals into
the heart, including the function of the heart. The classic
the pericardial sac through a pericardial catheter after the peri-
echocardiographic finding suggestive of cardiac tamponade is
cardial space has been drained. The purpose is to create an
collapse of the right atrium and ventricle because of the pres-
inflammatory response with resultant fibrosis and sclerosis to
sure of the increased pericardial fluid (Beauchamp, 1998).
prevent reaccumulation of fluid in the pericardial space. Some
One benefit of the 2-D echo is that it can be completed at bed-
of the chemicals used are doxycycline, bleomycin, cisplatin,
side if patients are too ill to be transported. Other imaging
or vinblastine (Hunter, 1998; Pass, 1993).
techniques used to detect cardiac tamponade may be magnetic
Surgical procedures also can provide effective palliative
resonance imaging and computerized tomography scans, both
treatment for recurrent malignant cardiac tamponade. A par-
of which can detect small and large effusions, pericardial
tial pericardiectomy, or pericardial window, creates a surgical
thickening, and pericardial masses (Lawler, 1999; Shepherd).
opening in the pericardium to drain fluid into the pleural or
Medical Management of Cardiac Tamponade
peritoneal compartments. However, pericardial drainage will
be less than optimal if a pleural effusion or peritoneal effusion
Cardiac tamponade is a life-threatening emergency. The
(i.e., ascites) already exists (Harken et al., 1997). A total peri-
immediate goal of treatment for cardiac tamponade is the re-
cardiectomy (i.e., removal of the visceral pericardium) is used
moval of the pericardial fluid to restore hemodynamic stabil-
to treat radiation-induced constrictive pericarditis (Hunter,
ity. The degree of decrease in cardiac output and hemody-
1998). These procedures are performed in the operating room
namic instability must be considered because emergency
under general anesthesia (Beauchamp, 1998). Another surgi-
intervention may be needed to prevent a fatal outcome.
cal procedure is percutaneous balloon pericardiotomy, which
Supportive care of patients with cardiac tamponade includes
uses a balloon-tipped catheter to tear the pericardium and cre-
ongoing pharmacologic therapy to maintain blood pressure and
ate a window for drainage. This procedure usually is per-
cardiac functioning during all treatment modalities (Uaje et al.,
formed in a cardiac catheterization lab.
1996). Mild cardiac tamponade initially may be treated cau-
After the patient has been stabilized, long-term goals can be
tiously with diuretics, such as furosemide or spironolactone, as
addressed, including treatment of any underlying malignancy
well as with corticosteroids, such as prednisone. Administration
(Schafer, 1997). Treatment choices will depend on patients'
of blood products, plasma, and saline will expand circulatory
primary diagnosis, performance status, and stage and aggres-
volume and delay circulatory collapse. Oxygen therapy may
siveness of the disease (Lawler, 1999; Mangan, 1992). Radia-
be initiated. Vasoactive drugs may be used to maintain perfu-
tion therapy can be used when tumors of the pericardium are
sion. Isoproterenol can increase heart rate and low-dose
radiosensitive. Radiation therapy is contraindicated when the
dopamine can improve cardiac contractility (Beauchamp,
area involved has been irradiated previously. Systemic anti-
1998; Braunwald, 1997; Schafer, 1997).
neoplastic therapy may be administered if the malignancy is
Several options for treatment of cardiac tamponade exist.
chemotherapy sensitive (DeMichele & Glick, 2001).
Percutaneous pericardiocentesis, a drainage technique fre-
quently used as the initial treatment for cardiac tamponade,
Nursing Care
also is useful as a diagnostic tool (Beauchamp, 1998; Harkin
et al., 1997; Knoop & Willenberg, 1999; Lawler, 1999; Man-
Recognition of early signs and symptoms of pericardial ef-
gan, 1992; Pass, 1993). Under guidance by either cardiac
fusion and cardiac tamponade can allow for treatment before
catheterization or 2-D echo, a needle is inserted percutane-
life-threatening circulatory collapse occurs. Nurses frequently
ously into the pericardial sac to aspirate the fluid and decom-
are able to perceive subtle changes in patient status. Accurate
press the tamponade. Echocardiographically guided peri-
and thorough ongoing assessment of cardiopulmonary and he-
cardiocentesis can be performed at bedside. Unguided
modynamic status is necessary to identify early abnormal
aspiration only should be used in extreme emergency situa-
changes. Nursing assessment includes strict monitoring of vi-
tions. The benefit of pericardiocentesis is that the tamponade
tal signs, including assessment for pulsus paradoxus, as well as
is relieved quickly, but complications of the procedure include
assessment of level of consciousness, ECG tracings, respiratory
puncture of the cardiac muscle, abscess, dysrhythmia, and
status, and skin and temperature changes (Smeltzer & Bare,
infection.
1996). Accurate monitoring of intake and output is necessary,
Pericardiocentesis also is useful as tool for cytologic diag-
including assessment for edema or oliguria and anuria. Regu-
nosis. The aspirated pericardial fluid is classified as either a
lar assessment also includes examination for positive
transudate or an exudate. A transudate, which has low protein
hepatojugular reflux as well as measurement of abdominal girth
levels, is a fluid that has leaked from blood vessels as a result
to detect ascites (Schafer, 1997).
FLOUNDERS VOL 30, NO 2, 2003
E51
therefore, patients may experience severe symptoms of heart
Nursing interventions include pain management, care of
failure (Keefe). Avoidance of anthracycline-induced cardi-
pericardial catheters, position changes to minimize shortness
omyopathy includes measurement of the ejection fraction and
of breath, postoperative care, and administration of oxygen
ongoing evaluation of patients for symptoms, including refer-
(Hunter, 1998; Schafer, 1997). Instructions regarding appro-
ral to a cardiologist for high-risk patients, monitoring cumu-
priate and timely physician notification of complications that
lative dose, and dose adjustment or discontinuation when nec-
occur after discharge can help to initiate early interventions.
essary. Treatment includes diuretics, digitalis, and angio-
Assessment and intervention for the side effects of radiation
tensin-converting enzyme inhibitors.
therapy, such as fatigue and skin alterations, as well as the side
Cardiac complications can occur as a side effect of other
effects of chemotherapy, such as nausea, vomiting, stomati-
cancer treatments. Trastuzumab (Herceptin [Genentech, Inc.,
tis, or pancytopenia, can aid in minimizing symptoms. Nurses
should assess for possible ineffective coping and depression.
South San Francisco, CA]) is a recently developed mono-
Referral for home nursing services or hospice care should be
clonal antibody to the HER2 receptor (Cooper & Cooper,
considered as needed.
2001; Keefe, 2000). The incidence of heart failure increases
when trastuzumab is administered in conjunction with an
Additional Cardiac Complications of Cancer Therapy
anthracycline such as doxorubicin or epirubicin. Therefore, a
In addition to pericardial effusion and cardiac tamponade,
baseline ejection fraction always should be obtained before
people with cancer may develop any cardiovascular disease
administration of trastuzumab to detect underlying asymp-
(Keefe, 2000). Oncology nurses should be aware that acute
tomatic left ventricular dysfunction (Keefe). Patients must be
heart failure might be a complication experienced by pa-
monitored closely during therapy with trastuzumab.
tients with cancer and that heart failure occasionally is
Cardiotoxicity also can be caused by administration of 5-
caused by the cancer treatment itself. Anthracyclines, such
fluorouracil, which can cause coronary artery spasm with re-
as doxorubicin, and the anthracenedione mitoxantrone can
sultant angina, dysrhythmias, myocardial infarction, cardiac
arrest, or sudden death (Keefe, 2000; Steinherz & Yahalom,
cause signs and symptoms of heart failure as a result of treat-
ment-induced cardiomyopathy caused by myocyte damage
1993). Cardiac toxicity occurs very rarely with initial doses
and myocardial cell loss (Keefe; Steinherz & Yahalom,
and is more common with subsequent doses toward the end of
1993). ECG changes that have been detected after adminis-
a five-day infusion. Deaths have been reported to occur in
symptomatic patients who continued therapy despite warning
tration of anthracyclines include supraventricular dys-
rhythmias, heart block, and ventricular tachycardia. In addi-
signs and symptoms (Keefe).
tion, ECG-gated pool scans can be completed to assess
Conclusion
global left ventricular function and ejection fraction. The
ECG-gated pool scan is a procedure in which the measured
Nurses must be aware that cardiac complications can occur
amount of radioactive tracer in the chambers of the heart is
as a complication of cancer treatment. Oncology nurses com-
proportional to the volume of blood in the chambers (Bul-
monly administer chemotherapy and have frequent and pro-
lock & Henze, 2000). ECG-gated pool scans have shown
longed encounters with patients. Ongoing, accurate, and thor-
major decreases in ejection fraction that reach a nadir within
ough cardiovascular assessment is necessary to detect dys-
2448 hours after anthracycline administration. As a result,
rhythmias or changes in functional status, such as increased
congestive heart failure can occur in certain patients (Chab-
weakness, decreased endurance, or exercise intolerance. Early
ner & Myers, 1993).
detection of subtle changes and signs and symptoms of car-
Tachycardia is the initial sign that an anthracycline is caus-
diac complications can prevent increased cardiotoxicity.
ing cardiomyopathy, followed by decreased exercise toler-
ance. However, these signs sometimes are overlooked and at-
The author would like to thank John Sprandio, MD, of Consultants in Medi-
tributed to other causes, such as anemia, pain, or fever
cal Oncology and Hematology, Drexel Hill, PA, for reviewing this manuscript.
(Keefe). Fluid overload occurs next. The response of a normal
heart to increased blood volume usually is dilatation of the
chambers of the heart and hypertrophy of the ventricles (Bul-
Author Contact: Jo Ann Flounders, MSN, CRNP, OCN, CHPN,
lock, 2000). However, anthracycline-induced cardiomyopathy
can be reached at joann@theflounders.com, with copy to editor at
is associated with little increase in left ventricular size, and,
rose_mary@earthlink.net.
References
Chabner, B., & Myers, C. (1993). Antitumor antibiotics. In V. DeVita, S.
Beauchamp, K. (1998). Pericardial tamponade: An oncologic emergency.
Hellman, & S. Rosenberg (Eds.), Cancer principles and practice of oncol-
Clinical Journal of Oncology Nursing, 2, 8595.
ogy (4th ed., pp. 374384). Philadelphia: Lippincott-Raven.
Bickley, L. (1999). Bates' guide to physical examination and history taking
Cooper, M., & Cooper, M. (2001). Systemic therapy. In R. Lenhard, R.
(7th ed.). Philadelphia: Lippincott.
Osteen, & T. Gansler (Eds.), Clinical oncology (pp. 175215). Atlanta, GA:
Braunwald, E. (1997). Cardiac tamponade. In E. Braunwald (Ed.), Heart dis-
American Cancer Society.
ease: A textbook of cardiovascular medicine (pp.14461496). Philadelphia:
DeMichele, A., & Glick, J. (2001). Cancer-related emergencies. In R.
Saunders.
Lenhard, R. Osteen, & T. Gansler (Eds.), Clinical oncology (pp. 733764).
Bullock, B. (2000). Altered cardiac function. In B. Bullock & R. Henze
Atlanta, GA: American Cancer Society.
(Eds.), Focus on pathophysiology (pp. 455502). Philadelphia: Lip-
Dietz, K., & Flaherty, A. (1993). Oncologic emergencies. In S. Groenwald, M.
pincott.
Frogge, M. Goodman, & C. Yarbro (Eds.), Cancer nursing (3rd ed., pp.
Bullock, B., & Henze, R. (Eds.). (2000). Focus on pathophysiology. Philadel-
800839). Boston: Jones and Bartlett.
phia: Lippincott.
ONF VOL 30, NO 2, 2003
E52
Harken, A., Hammond, G., & Edmunds, L. (1997). Pericardial diseases. In L.
Frogge, M. Goodman, & C. Yarbro (Eds.), Cancer nursing (4th ed., pp.
Edmunds (Ed.), Cardiac surgery in the adult (pp.13031317). New York:
721741). Boston: Jones and Bartlett.
McGraw Hill.
McAllister, H., Hall, R., & Cooley, D. (1999). Tumors of the heart and peri-
Hunter, J. (1998). Structural emergencies. In J. Itano & K. Taoka (Eds.), Core
cardium. Current Problems in Cardiology, 24, 57116.
curriculum for oncology nursing (3rd ed., pp. 340354). Philadelphia:
Pass, H. (1993). Malignant pleural and pericardial effusions. In V. DeVita, S.
Saunders.
Hellman, & S. Rosenberg (Eds.), Cancer principles and practice of oncol-
Keefe, D. (2000). Cardiovascular emergencies in the cancer patient. Seminars
ogy (pp. 25862598). Philadelphia: Lippincott-Raven.
in Oncology, 27, 244255.
Schafer, S. (1997). Oncologic complications. In S. Otto (Ed.), Oncology nurs-
Knoop, T., & Willenberg, K. (1999). Cardiac tamponade. Seminars in Oncol-
ing (3rd ed., pp. 406476). St. Louis: Mosby.
ogy Nursing, 15, 168173.
Shepherd, F. (1997). Malignant pericardial effusion. Current Opinion in On-
Lawler, P. (1999). Effusions. In C. Yarbro, M. Frogge, & M. Goodman (Eds.),
cology, 9, 170174.
Cancer symptom management (2nd ed., pp. 419433). Boston: Jones and
Smeltzer, S., & Bare, B. (1996). Oncology: Nursing the patient with cancer. In
Bartlett.
S. Smeltzer & B. Bare (Eds.), Brunner and Suddarth's textbook of medical-
Mangan, C. (1992). Malignant pericardial effusions: Pathophysiology and
surgical nursing (8th ed., pp. 309316). Philadelphia: Lippincott-Raven.
clinical correlates. Oncology Nursing Forum, 19, 12151223.
Steinherz, L., & Yahalom, J. (1993). In V. DeVita, S. Hellman, & S. Rosen-
Markiewicz, W., Borovik, R., & Ecker, S. (1986). Cardiac tamponade in
berg (Eds.), Cancer principles and practice of oncology (pp. 23702385).
medical patients: Treatment and prognosis in the echocardiographic era.
Philadelphia: Lippincott-Raven.
American Heart Journal, 111, 11381142.
Uaje, C., Kahsen, K., & Parish, L. (1996). Oncology emergencies. Critical
Maxwell, M. (1997). Malignant effusions and edemas. In S. Groenwald, M.
Care Nursing Quarterly, 18(4), 2634.
FLOUNDERS VOL 30, NO 2, 2003
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ONF Continuing Education Examination
Cardiovascular Emergencies: Pericardial Effusion and Cardiac Tamponade
Contact Hours: 1.1
cal treatment. The medical intervention that would first
Passing Score: 80%
be used is
Test ID #: 03-30/2-01
a. Administering diuretics and corticosteroids.
Test Processing Fee: $15
b. Removing the fluid from the pericardial space.
c. Administering saline to expand circulatory volume.
The Oncology Nursing Society is accredited as a provider
d. Administering vasoactive drugs to maintain perfusion.
of continuing education (CE) in nursing by the
8.
Mr. Smith underwent a pericardiocentesis. The aspirated
American Nurses Credentialing Center's Commission on
pericardial fluid was sent for cytology. What character-
Accreditation.
istic of this fluid would indicate it is a malignant effu-
California Board of Nursing, Provider #2850.
sion?
a. Low protein levels
CE Test Questions
b. Clear straw color
1. A client is seen in the emergency room with a diagnosis
c. Low specific gravity
of early pericardial effusion with tamponade. The nurse
d. Contained cellular debris
could expect the patient to describe
9.
Ms. Broad is receiving her fourth cycle of doxorubicin.
a. Peripheral edema, confusion, and dyspnea.
Which assessment finding may first indicate that Ms.
b. Coughing, weakness, palpitations, and dyspnea.
Broad is developing cardiomyopathy?
c. Restlessness, constant chest pain, and progressive dys-
a. Dyspnea
pnea.
b. Tachycardia
d. Dyspnea, apprehension, and increasing chest pain
c. Hemoglobin of 9.5 g/dL
without relief.
d. Decreased exercise tolerance
2. The diagnostic procedure with the highest sensitivity of
10.
Mr. Brown has a pericardial effusion with tamponade. He
detecting a pericardial effusion or cardiac tamponade is
is most likely to describe chest pain that
a. Routine chest x-ray film.
a. Decreases when lying on his back.
b. Electrocardiogram.
b. Is worse in the morning than evening.
c. Positron emission tomography.
c. Is constant despite position or activity.
d. Two-dimensional echocardiogram.
d. Decreases when he is leaning forward.
3. Cardiac tamponade is best defined as excessive fluid in
11.
Ms. Cord has Her2-neu-positive breast cancer and has
the
been ordered to receive trastuzumab and doxirubicin.
a. Pericardium that leads to increased ventricular filling
What assessment study should be performed prior to be-
and decreased cardiac output.
ginning this regimen?
b. Pericardial space that leads to increased pericardial
a. Chest x-ray
pressure and increased cardiac output.
b. Ejection fraction
c. Pericardial sac that leads to increased pericardial effu-
c. Echocardiogram
sion and increased pressure on the heart.
d. Electrocardiogram
d. Pericardial space that leads to increased pericardial
12.
A client is receiving the last day of chemotherapy of her
pressure and decreased systemic perfusion.
third cycle. She begins to complain of steady and severe
4. A patient with a stage III breast cancer of her left breast
pain in her chest that is radiating down her left arm.
is considered at risk for developing cardiac tamponade
Which chemotherapy agent is she receiving that may
primarily because of her
cause these symptoms?
a. Treatment with paclitaxel.
a. 5-fluoruracil
b. Breast cancer diagnosis.
b. Epirubicin
c. History of congestive heart failure.
c. Doxorubicin
d. Treatment with radiation therapy of 3000 cGy.
d. Trastuzumab
5. Which nursing diagnosis should the nurse plan to address
13.
A patient is to undergo a partial pericardiectomy. This
first for a patient with pericardial effusion?
procedure is best described as
a. Risk for pain
a. A surgical procedure where the visceral pericardium
b. Risk for infection
is removed.
c. Risk for ineffective coping
b. A surgical procedure that will create a window in the
d. Risk for alteration in cardiac output
pericardium to drain fluid into the pleural compart-
6. What physical examination findings would be consistent
ments.
with early signs of cardiac tamponade?
c. A procedure performed in the radiology department
a. Pulsus paradoxus
where a needle will be inserted into the pericardial sac
b. Muffled heart sounds
to aspirate the pericardial fluid.
c. Narrowing pulse pressure
d. A procedure performed in the cardiac catherization lab
d. Tachycardia of 125 beats per minute
that uses a balloon-tipped catheter to tear the pericar-
7. Ms. Jones has a cardiac tamponade and will require medi-
dium to create a window for drainage.
ONF VOL 30, NO 2, 2003
E54
14. A patient is to have chemicals installed into the pericar-
16. A patient with which type of cancer is at the least risk for
dial sac after the space has been drained. What is the ra-
developing pericardial tamponade?
tionale for this procedure?
a. Leukemia
a. Pericardial washings to prevent collapse of the peri-
b. Lung cancer
cardial sac
c. Spinal cord tumor
b. Pericardial sclerosis to remove any malignant effusion
d. Esophageal cancer
that remained
17. Which is the most appropriate statement regarding the
c. Pericardial scraping to deliver cytotoxic agents to the
difference between pericardial effusion and cardiac tam-
site of metastasis
ponade?
d. Pericardial sclerosis to create an inflammatory re-
a. Cardiac tamponade is an anatomic diagnosis with no
sponse with resultant fibrosis and sclerosis
hemodynamic consequences.
15. What nursing interventions are essential for early detec-
b. Pericardial effusion is a physiologic diagnosis with no
tion of cardiac tamponade in high-risk patients?
hemodynamic consequences.
a. Evaluation of daily electrocardiogram tracings
c. Cardiac tamponade is a physiologic diagnosis with re-
b. Frequent monitoring of vital signs
sultant hemodynamic consequences.
c. Daily evaluation of input and output
d. Pericardial effusion is an anatomic diagnosis that has
d. Evaluation of daily electrolyte lab results
resultant hemodynamic consequences.
Oncology Nursing Forum Answer/Enrollment Form
Cardiovascular Emergencies: Pericardial Effusion and Cardiac Tamponade (Test ID #03-30/2-01)
4. The deadline for submitting the answer/enrollment form is
To receive continuing education (CE) credit for this issue, simply
1. Read the article.
two years from the date of this issue.
2. Print this page and indicate your answers on the form. Also,
5. Contact hours will be awarded to RNs who successfully com-
complete the program evaluation.
plete the program. Successful completion is defined as an
3. Mail the completed answer/enrollment form along with a
80% correct score on the examination and a completed evalu-
check or money order for $15 per test payable to the Oncol-
ation program. Verification of your CE credit will be sent to
ogy Nursing Society. Payment must be included for your ex-
you. Certificates will be mailed within six weeks following
amination to be processed.
receipt of your Answer/Enrollment Form. For more infor-
mation, call 866-257-4667, ext. 6296.
8.
9.
1.
5.
2.
6.
7.
4.
3.
a  10.
a
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a
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a
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a
a
a
Instructions: Mark
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your answers clearly by
c
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c
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c
placing an "x" in the
d
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box next to the correct
answer. This is a stan-
11.
a  20.
a
a 18.
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a 12.
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dard form; use only the
b
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number of spaces re-
c
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quired for the test you
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Program Evaluation
1. How relevant were the objectives to the CE activity's goal?
2. How well did you meet the CE activity's objectives (see page E48)?
Objective #1
Objective #2
Objective #3
3. To what degree were the teaching/learning resources helpful?
Too basic
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4. Based on your previous knowledge and experience, do you think
that the level of the information presented in the CE activity was
minutes
5. How long did it take you to complete the CE activity?
My check or money order payable to the Oncology Nursing Society is enclosed. U.S. currency only. (Do not send cash.)
After completing this form, mail it to: Oncology Nursing Society, P.O. Box 3510, Pittsburgh, PA 15230-3510.
For more information or information on the status of CE certificates, call 866-257-4667, ext. 6296.
FLOUNDERS VOLNO 2, 20032003
ONF VOL 30, 30, NO 2,
E55