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cardio.cardiac-tamponade.purulent-bacterial.v1

Cardiac tamponade — purulent bacterial pericarditis

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to purulent (bacterial) pericarditis (S. aureus ~50% including MRSA, S. pneumoniae + other streptococci ~20-25%, gram-negatives ~10-15%, anaerobes for esophageal / dental sources). Routes: contiguous spread from pneumonia / empyema / mediastinitis (especially post-CABG / post-esophageal surgery), hematogenous from endocarditis or bacteremia, direct inoculation (penetrating trauma, post-cardiothoracic surgery), and immune-suppression-related (HIV, chemotherapy, ESRD). High-mortality (40-77%) condition requiring DUAL emergent management — pericardial drainage (subxiphoid surgical window PREFERRED over needle pericardiocentesis alone for thick pus + loculations) + immediate empiric IV antibiotics within 1 hour per Surviving Sepsis 2026 (vancomycin 15-20 mg/kg AUC-targeted + ceftriaxone 2 g daily; expand to anti-Pseudomonal cefepime / piperacillin-tazobactam + add metronidazole if post-thoracic surgery / esophageal perforation / immunocompromised); intrapericardial fibrinolytics (streptokinase 250,000-500,000 U or alteplase 10-25 mg q24h × 3-7d) per Maisch ESC 2004 + Tomkowski 2008 to dissolve fibrin loculations + reduce constriction risk; sepsis bundle (30 mL/kg crystalloid + norepinephrine for MAP ≥65 + source control); pericardiectomy if complete drainage cannot be achieved or constriction develops (~25-35% of survivors per Augustin EJCTS 2011). Severity triggers cover septic shock with tamponade dual-hit, inadequate drainage with persistent loculation, MRSA / MDR organism requiring alternative therapy, constrictive pericarditis development post-recovery, concurrent endocarditis / mediastinitis requiring extended antibiotics + concurrent surgery. Sister-differentiated from TB pericarditis (subacute granulomatous), uremic (metabolic, intensified HD first), and malignant (neoplastic, drainage + cytotoxics). Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (purulent-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated antibiotic codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (6)

  • symptom
    Septic-appearing patient (fever, tachycardia, hypotension) with pericardial effusion + Beck triad — purulent pericarditis until proven otherwise; mortality 40-77% (ESC 2015 §Purulent Pericarditis; Pankuweit Heart 2013 PMID 23257306)
    sepsis_with_pericardial_effusion_and_tamponade_physiology
  • history
    Pneumonia / empyema (especially S. pneumoniae or staph) developing new pericardial effusion → contiguous spread purulent pericarditis (Sagristà-Sauleda EHJ 2002 PMID 12122206)
    pneumonia_or_empyema_with_new_pericardial_effusion
  • history
    Post-cardiothoracic surgery (CABG, valve, esophagectomy) within 30 days with new pericardial effusion + sternal wound drainage / fever / leukocytosis → mediastinitis with contiguous spread (gram-negatives + MRSA; Augustin EJCTS 2011)
    post_cardiothoracic_or_esophageal_surgery_with_mediastinitis
  • history
    Documented bacteremia (especially S. aureus) or known infective endocarditis with new pericardial effusion → hematogenous seeding (ESC 2023 Endocarditis PMID 37622656)
    bacteremia_or_endocarditis_with_pericardial_effusion
  • imaging
    Echo: thick fibrinous / loculated pericardial effusion with septations + RV diastolic collapse + IVC plethora — purulent pattern characteristic (ESC 2015 §Purulent)
    echo_thick_loculated_pericardial_effusion_with_fibrin
  • lab_abnormality
    Pericardial fluid grossly purulent on tap — frank pus / >10,000 PMN/μL / glucose <40 mg/dL / positive gram stain → emergent ID + cardiothoracic surgery activation (Pankuweit Heart 2013)
    pericardial_fluid_grossly_purulent_with_pmn_predominance

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Older + immunocompromised patients have higher mortality + atypical organism distribution (Pankuweit Heart 2013 PMID 23257306)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad; superimposed septic shock in purulent pericarditis (Surviving Sepsis 2026)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachycardia + sepsis-driven tachycardia (ESC 2015)
  • temperaturerequired
    vital • used at INITIAL_WORKUP
    Fever is a defining feature; quantify pattern + height; absent fever in elderly / immunocompromised does NOT exclude (Pankuweit Heart 2013)
  • echorequired
    imaging • used at INITIAL_WORKUP
    Definitive bedside dx — chamber collapse, IVC, swinging heart; thick fibrinous loculated pattern characteristic of purulent etiology (ESC 2015 Class I)
  • source_of_infection_and_immunocompromise_statusrequired
    history • used at CONTEXT
    Pneumonia, empyema, mediastinitis, endocarditis, dental sepsis, bacteremia, recent cardiothoracic / esophageal surgery, HIV, chemo, ESRD — drives empiric antibiotic + surgical strategy (ESC 2015; Augustin EJCTS 2011)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Sepsis-driven hypoperfusion marker; ≥2 mmol/L drives sepsis bundle activation per Surviving Sepsis 2026
  • wbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis with left shift typical; leukopenia in severe sepsis / immunocompromised — both ominous (Pankuweit Heart 2013)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Baseline for vancomycin AUC dosing + sepsis-related AKI tracking + contrast for chest CT (IDSA 2024 MRSA)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    Sepsis / DIC platelet consumption + drainage bleeding risk (Surviving Sepsis 2026)
  • chest_imaging_for_pneumonia_empyema_mediastinitisrequired
    imaging • used at INITIAL_WORKUP
    CXR + low-threshold chest CT to identify primary source (pneumonia, empyema, mediastinal abscess, esophageal perforation); positive findings strengthen diagnosis + guide source control (ESC 2015 §Purulent)

12-phase flow (9)

  1. 1FRAME
    Purulent bacterial tamponade — EMERGENT drainage (subxiphoid window preferred over needle alone for thick pus + loculations) + immediate empiric IV antibiotics covering MRSA + streptococci + gram-negatives + source control + intrapericardial fibrinolytics to prevent constriction; mortality 40-77% even with optimal therapy (ESC 2015; Pankuweit Heart 2013 PMID 23257306)
    inputs: sbp
    advance: purulent-context tamponade physiology suspected
  2. 2ENTRY
    Recognize septic-appearing patient with Beck triad in setting of pneumonia/empyema/mediastinitis/bacteremia/endocarditis/post-cardiothoracic surgery; rule in purulent vs viral vs autoimmune vs malignant (Sagristà-Sauleda EHJ 2002 PMID 12122206)
    inputs: age
    advance: purulent-context risk factors confirmed
  3. 3CONTEXT
    Document infection source (pneumonia/empyema/mediastinitis/endocarditis/bacteremia/dental/post-surgical), immune status (HIV/chemo/ESRD/transplant), prior antibiotic exposure, recent procedures, MRSA / MDR colonization (ESC 2015; Augustin EJCTS 2011)
    inputs: source_of_infection_and_immunocompromise_status
    advance: purulent context + sources fully captured
  4. 4RED_FLAGS
    Tamponade obstructive shock + concurrent septic shock physiology — DUAL HIT requires aggressive concurrent management (Surviving Sepsis 2026; ESC 2015)
    inputs: sbp, hr
    advance: tamponade + sepsis dual-shock recognized → emergent drainage + sepsis bundle
  5. 5INITIAL_WORKUP
    STAT echo, ECG, CXR, low-threshold chest CT, blood cultures × 2 BEFORE antibiotics, lactate, BMP, CBC with diff, coags, CRP, procalcitonin; pericardial fluid for gram stain + culture + PMN count + glucose + LDH + cytology (Pankuweit Heart 2013; Surviving Sepsis 2026)
    inputs: echo, lactate, wbc, creatinine, platelets, temperature, chest_imaging_for_pneumonia_empyema_mediastinitis
    actions: panel.cardiac, panel.renal, panel.cbc, panel.coag
    advance: echo confirms tamponade + sepsis workup initiated + cultures drawn
  6. 6DIFFERENTIAL
    Pericardial fluid analysis: PMN-predominant (>10,000/μL), glucose <40 mg/dL, LDH high, protein high, gram stain + culture (aerobic + anaerobic + fungal + AFB), cytology, ADA (excludes TB), MALDI-TOF / 16S PCR for organism identification; blood cultures + source-site cultures (sputum, urine, wound, sternal swab) (Pankuweit Heart 2013; ESC 2015)
    advance: fluid + blood + source-site cultures sent for full workup
  7. 7TREATMENT
    Step 1 EMERGENT subxiphoid pericardial window with pigtail drainage placement (preferred over needle pericardiocentesis alone — incomplete drainage of thick pus); Step 2 empiric IV vancomycin 15-20 mg/kg q8-12h (AUC-targeted) + ceftriaxone 2 g IV daily WITHIN 1 HOUR of recognition per Surviving Sepsis 2026; expand to anti-Pseudomonal beta-lactam (cefepime 2 g q8h or piperacillin-tazobactam 4.5 g q6h) + metronidazole 500 mg IV q8h if post-thoracic-surgery / esophageal perforation / immunocompromised; Step 3 intrapericardial irrigation + fibrinolytics (streptokinase 250,000-500,000 U or alteplase 10-25 mg) to prevent loculation per Maisch ESC 2004 + Tomkowski 2008; Step 4 sepsis bundle (30 mL/kg crystalloid if hypotensive + lactate >4, norepinephrine for MAP ≥65, source control); Step 5 pericardiectomy if complete drainage cannot be achieved or constriction develops (Augustin EJCTS 2011); Step 6 narrow antibiotics per culture + susceptibility within 48-72h (ESC 2015; Pankuweit Heart 2013)
    inputs: sbp
    advance: drainage + IV antibiotics within 1h + sepsis bundle initiated + surgical disposition determined
  8. 8DISPOSITION
    CCU/ICU mandatory for dual-shock + sepsis management; ID + cardiothoracic surgery + cardiology + critical care multidisciplinary team; consider source-specific specialty (pulmonology for empyema, GI for esophageal perforation) (ESC 2015)
    advance: multidisciplinary ICU disposition confirmed
  9. 9MONITORING
    Re-accumulation surveillance (echo q12-24h initially then daily then per response); drainage output + character; daily blood cultures until clearance; CRP / procalcitonin trend; serial chest CT at 7d for source-control assessment; vancomycin AUC + trough monitoring; constriction surveillance (ESC 2015 §Follow-up; Pankuweit Heart 2013)
    actions: panel.cardiac
    advance: antibiotic response + drainage adequacy documented + constriction surveillance ongoing