Transcript Pericardial Tamponade - University of North Carolina at

Cardiac Tamponade
Cardiac Tamponade
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Normal amt of pericardial fluid = 20-50 mL
Tamponade occurs when lg or rapidly formed
effusions  inc’d pressure in the pericardial space
throughout the cardiac cycle
During inspiration, RV volume inc’s & in tamponade,
the RV is unable to expand into the maximally
stretched pericardium  L-ward bulging of the
interventricular septum  dec’d LVEDV  dec’d
cardiac output & dec’d SBP during inspiration
Etiology of Cardiac Tamponade
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HIV, bacterial (incl mycobacterial), viral, fungal
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CA - Esp lung, breast, Hodgkin’s, mesothelioma
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Radiation tx
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Meds - Hydralazine, Procainamide, INH, Minoxidil
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Post-MI (free wall ventricular rupture, Dressler’s syndrome)
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Connective tissue dzs – SLE, RA, Dermatomyositis
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Uremia
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Trauma
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Iatrogenic – (eg, from TLC / PA Cath / TV pacemaker insertion, coronary
dissection & perforation, sternal bx, pericardiocentesis, GE jnx surgeries)
Other - Pneumopericardium (d/t mech ventilation or gastropericardial
fistula), Pleural effusions
Idiopathic
Clinical Presentation
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Sxs
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Chest Pain, dyspnea, near-syncope
Generally more comfortable sitting forward
Sxs c/w the underlying cause of tamponade
Physical Exam
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Beck’s Triad - Elev’d JVP, hypotension, dec’d heart sounds
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JVP w/ preserved x descent and dampened or absent y descent
Generally w/ narrow pulse pressure
Tachycardia, other signs of HF (tachypnea, diaphoresis, cool
extremities, cyanosis, etc)
Pulsus paradoxus
Dec’d or absent cardiac impulse
+/- Friction rub
Pulsus “Paradoxus”
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Dec in SBP > 10-12 mmHg
w/ inspiration
Can also occur in pts w/
COPD, pulm dz, PTX,
severe asthma
Can have tamponade
w/o pulsus paradoxus
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In pts w/ pre-existing
elev’s in diastolic
pressures and/or volume
(eg, LV dysfnx, AI and
ASD)
Diagnosis
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Tamponade is a Clinical Diagnosis
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Other Detection Methods
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EKG
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CXR
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TTE
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R Heart Cath
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CT, MRI
EKG Findings
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Common Findings
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Sinus tachycardia
Non-specific ST segment and T wave changes
Changes assoc’d w/ acute pericarditis (incl diffuse STE & PR
depression)
Other Findings
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Dec’d voltage (non-specific and can also be d/t emphysema,
infiltrative myocardial dz, PTX, etc)
Electrical alternans (specific but relatively insensitive for lg
effusions)
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2/2 anterior-posterior swinging of the heart w/ each beat
Best seen in leads V2 to V4
Combined P wave and QRS complex alternation (specific for
cardiac tamponade)
EKG Findings
CXR Findings
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Sudden inc in size of
cardiac silhouette w/o
specific chamber
enlargement
Effacement of the
normal cardiac borders
Development of a “flask”
or “H2O-bottle” shaped
heart
Lateral CXR Findings
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May have (+) fat pad sign
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Separation of mediastinal /
retrosternal fat and
epicardial fat by > 2 mm
TTE
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Test of choice for rapid assessment of pericardial effusions, but these
findings are often absent in pts w/ pulm HTN or RVH
Characteristic Findings
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Pericardial effusion
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End-diastolic chamber collapse
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RV expiratory collapse in early diastole (low sens, high spec)
RA expiratory collapse in late diastole (high spec if inward movement lasts > 30%
of cardiac cycle)
LA collapse (present in ~ 25%, highly spec)
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Transmitral resp varn > 25% transtricuspid varn > 50% are char of tamponade.
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Size often correlates w/ risk of tamponade but not always
Respiratory variation in transvalvular velocities during passive diastolic
filling.
IVC dilated & fails to collapse w/ inspiration (reflects elev’d CVP)
Small cardiac chambers
Swinging of the heart anteroposteriorly w/in the pericardial effusion
Reciprocal size changes w/ respiration b/w RV & LV & their valves
TTE w/ Large Pericardial Effusion
R Heart Cath
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Near equalization
(w/in 5 mm Hg) of
the RA, RV, PCWP,
RV diastolic, & LV
diastolic pressures
RA pressure
tracings show
diminshed systolic
y descent
Tx of Cardiac Tamponade
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If mild, can sometimes tx w/ medical mgmt
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Including 1 or more of the following: NSAIDs,
Colchcine, and/or steroids, depending on the
suspected cause.
Require very close monitoring, including w/ serial
TTEs and/or RHC
Tx of Cardiac Tamponade
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Most require urgent/emergent pericardiocentesis
Closed pericardiocentesis
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Open Pericardiocentesis in the OR
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Generally in cath lab but can be at bedside
Subxiphoid approach under echo guidance is most common minimizes risk & can assess completeness of fluid removal
Can alternatively use Fluoroscopic guidance
Pigtail catheter often left in place
May be best for loculated effusions, effusions containing clots or
fibrinous material, and/or effusions that are borderline in size
Allow for bx and creation of a pericardial window for recurrent
effusions
Bedside pericardiocentesis if pt is in extremis
Emergency Bedside Pericardiocentesis
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16- or 18-gauge
needle inserted at
angle of 30-45° to
the skin, near the
left xiphocostal
angle, aiming toward
the L shoulder
Tx of Cardiac Tamponade – Other Measures
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IVFs, especially if hypovolemic or if diuretics were
given for dx of HF
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Temporary inotropic support (Dobutamine,
Dopamine)
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Serial echos after draining the fluid
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Analysis of pericardial fluid
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Only has a low yield in determining the etiology of
pericardial dz
Can send for specific gravity, pH, glc, LDH, protein, cell
count, cytology, staining & Cx for bacteria, fungi, & TB).
Tx of Recurrent Effusions
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Pericardectomy
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Pericardial-peritoneal shunt
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Pericardiodesis - Steroids, tetracycline, or
anti-neoplastic drugs administered into the
pericardial space  sclerosis of the
pericardium
References
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Spodick, DH. Acute cardiac tamponade. N Engl J Med 2003; 349:684.
Internet Journal of Anesthesiology 2001: Cardiac Tamponade
Secondary To Suppurative Pericarditis. A Case Report And Review Of
The Literature
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Troughton, RW, Asher, CR, Klein, AL. Pericarditis. Lancet 2004;
363:717.
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Reddy, PS, Curtiss, EI, O'Toole, JD, Shaver, JA. Cardiac tamponade:
hemodynamic observations in man. Circulation 1978; 58:265.
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Roy, CL, et al. Does this patient with a pericardial effusion have cardiac
tamponade. NEJM 2007; 297(16):1810-1818
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MD Consult Books
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Libby – Braunwald’s Heart Disease
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Roberts – Clinical Procedures in Emergency Medicine
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Adam – Grainger & Allison’s Diagnostic Radiology
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Goldman - Cecil Medicine
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