This handout is for cardiac tamponade — post-procedural / hemopericardium / iatrogenic. Your care team identified this based on: acute hemodynamic decompensation in cath lab or ep lab during/post procedure → coronary perforation or la/ra wall perforation (holmes jacc 2011; cappato care 2013).
Other reasons your team may use this plan: new chest pain + dyspnea + rbbb pattern hours-to-days post pacer/icd implant → lead perforation (cano ajc 2010); post-cardiac-surgery hemodynamic decompensation in first 7d → post-cardiotomy tamponade or post-pericardiotomy syndrome (imazio circs nejm 2015 pmid 26315582); penetrating chest trauma to cardiac box or blunt sternal trauma with new dyspnea/hypotension → traumatic hemopericardium (esc 2015 §trauma).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| normal saline | 500-1000 mL bolus | IV | rapid bolus then reassess | Bridge preload (ESC 2015) |
| norepinephrine | 0.05-0.1 µg/kg/min titrate to MAP ≥65 | IV | continuous | Bridge only — does not address obstruction (Roy JAMA 2007) |
| protamine | 1 mg per 100 U UFH (max 50 mg single dose) | IV | slow IV over 10 min | Reverse UFH; ESC 2015; standard cath lab tamponade reversal |
| phytonadione | 10 mg IV slow over 10 min | IV | single dose | Vit K reverses warfarin synthesis defect; works over 6-12h (Bhatt Circulation 2018) |
| 4-factor prothrombin complex concentrate | 25-50 U/kg based on INR | IV | single dose | Immediate factor replacement for warfarin reversal in major bleeding (Bhatt Circulation 2018) |
| idarucizumab | 5 g IV (2 × 2.5 g vials) | IV | single dose | RE-VERSE AD (Pollack NEJM 2017 PMID 28793172) — complete reversal within minutes |
| andexanet alfa | low dose 400 mg bolus + 4 mg/min × 2h OR high dose 800 mg bolus + 8 mg/min × 2h based on FXa-DOAC dose + timing | IV | bolus + infusion | ANNEXA-4 (Connolly NEJM 2019 PMID 30730782) — rapid anti-FXa reversal |
| tranexamic acid | 1 g IV over 10 min then 1 g over 8h | IV | bolus + infusion | CRASH-2 PMID 20554319 trauma application; consider in traumatic hemopericardium per damage-control resuscitation principles |
Plan: Iatrogenic tamponade — emergent drainage + anticoagulation reversal + surgical readiness (ESC 2015 §Iatrogenic; Bhatt Circulation 2018)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Guideline: 2015 ESC Guidelines for the diagnosis and management of pericardial diseases (Adler EHJ 2015 PMID 26320112) §Iatrogenic Tamponade — remains current as of 2026-05-14. Holmes JACC 2011 (post-PCI), Cano AJC 2010 (lead perforation), Cappato Circ Arrhythm Electrophysiol 2013 (post-AF ablation), Imazio CIRCS NEJM 2015 PMID 26315582 (post-pericardiotomy), and Bhatt Circulation 2018 + Pollack NEJM 2017 (RE-VERSE AD) + Connolly NEJM 2019 (ANNEXA-4) anchor iatrogenic-specific reversal + surgical activation pathways.