Transcript ADEM- Acute Disseminated EncephaloMyelitis in children

INTRODUCTION
 Presence of abnormal amount and/or character of
fluid in the pericardial space
 Can be caused by LOCAL/SYSTEMIC/IDIOPATHIC
causes
 Can be ACUTE or CHRONIC (symptoms)
 Important implications for prognosis (intrathoracic
neoplasm), diagnosis (myopercarditis) or both
(dissecting of ascentding aorta)
 Treatment directed at removal of pericardial fluid
and alleviation of the underlying cause
PHYSIOLOGY
 Volume of fluid: 15-50 ml.
 Essentially and ultrafiltrate of plasma
 Total protein generally low. Albumin conc. HIGH.
 Contribution of pericardial fluid:
end-diastolic pressure (mostly RA,RV)
ensure uniform contraction of the myocardium
 Acute (80ml) vs. Chronic (up to 2lt).
ETIOLOGY
 As a component of any pericardial disorder or 2ry
to a systemic disorder:
 Acute idiopathic or viral pericaditis
 Infectious: Viral, Purulent pericarditis, Tuberculous, HIV
 Post MI/post cardiac surgery
 Malignancy (lung, breast, hodgkin’s, mesothelioma)
 Mediastinal radiation
 Autoimmune disease
 Dialysis, Ch. Renal failure
 Hypothyroidism (myxedema), ovarian hyperstimulation synd.
 Drugs: procainamide, isoniazid, hydralazine, anticoagulants.
ETIOLOGY
 HEMORRHAGIC PERICARDIAL EFFUSION:
 Malignancy (26%)
 Trans-catheter interventions and/or pacemaker insertion (18%)
 Post-pericardiotomy syndrome (13%)
 Complication of MI (free wall rupture, thrombolysis) (11%)
 Idiopathic (10%)
 Uremic (7%)
 Aortic dissection (4%)
 Trauma (3%)
 Other (8%)
CLINICAL- SYMPTOMS
 CVS: chest pain, pericardial pain (relieved by sitting),
light headedness, syncope, palpitations
 RESP: cough, dyspnea, hoarsness
 GI: hiccoughs
 NEUR: anxiety, confusion
CLINICAL- SIGNS
 CVS: BECK’s triad of tamponade (hypotension,
muffled heart sounds, jugular venous distension),
pulsus paradoxus, pericardial friction rub,
tachycardia, hepatojugular reflux.
 RESP: tachypnea, decreased breath sounds, Ewart
sign
 GI: hepato-splenomegaly
 EXTREMITIES: weakened peripheral pulses, edema,
cyanosis.
DIAGNOSIS
 Suspect when:
 All cases of acute pericarditis
 Unexplained persistent fever +\- source. Purulent
per.
 New radiographic cardiomegaly without pul.
Congestion.
 Isolated left pleural effusion
 Hemodynamic deterioration after MI, cardiac
surgery, invasive cardiac procedures.
APPRAOCH
 Clinically, ECG, X-RAY.
 Once pericardial effusion is suspected:
 Establish the presence of effusion : clinically ECG,
ECHO (sensitive, specific, hemodynamic significance
 Assess the hemodynamic impact
 Establish the cause
Establish the presence of effusion
 According to ACC/AHA/ASE 2003
 Clinically – insensitive and nonspecific.
 ECG- low voltage QRS complexes <5mm in all limb
leads, <10mm in V1-V6. (tamponade and
inflammation); alternans in P and QRS complexespathognomonic.
 ECHO: sensitive, specific, hemodynamic
significance
 CT, MRI
Assess hemodynamic impact
 Ranges from no significance mild
compromisecardiac tamponade
 Factors determining the degree of hemodynamic
compromise:
1. Volume
2. Rate of accumulation (acute vs. subacute)
3. Pericardium is scarred or adherent
Establish the cause of effusion
 Often recognized by the clinical setting in which it occurs
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(cancer, MI, hypothyroidism, renal failure)
Chance of diagnosis rises as the effusion is larger. (15/20%
vs. 90%; why? Diag., aggressive approach)
Clinical assess.: size; +/- tamponade; inflammatory signs
(chest pain, pericardial friction rub, fever diffused ST elev.)
Lab. Tests: CBC, chemistry+renal function, thyroid, anti
dsDNA,complement, chst CT
Pericardiocentesis & biopsy : culture, cytology, PCR.
protein,LDH,Glucose,RBC,WBC: do not distinguish
exudate from transudate
TREATMENT
 CONSIDER: underlying disease, hemodynamic
significance, presence of tamponade.
 Underlying disease: infectious, malignant, uremic
peric. MI, collagen vascular disease.
 Cardiac tamponade: volume resuscitation (RA
pressure 10-12mmHg).
 Pericardial fluid drainage: percutaneous/
pericadiectomy.
Summery
 Abnormal amount/character of pericardial fluid
 LOCAL/SYSTEMIC/IDIOPATHIC causes
 ACUTE vs. CHRONIC
 Clinical – not specific. Tamponade.
 APPROACH: Clinically, ECG, X-RAY; Establish the
presence of effusion ; Assess the hemodynamic impact
Establish the cause
 TREATMENT: underlying disease, hemodynamic
significance, presence of tamponade.