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Cardiac tamponade gk

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  • 1. Cardiac Tamponade 3 possible pericardial compression syndromes  Cardiac tamponade  accumulation of pericardial fluid under pressure and may be acute or subacute  Constrictive pericarditis  scarring and consequent loss of elasticity of the pericardial sac  Effusive-constrictive pericarditis  constrictive physiology with a coexisting pericardial effusion  Chicken or egg? Elevated wedge and Rt sided pressures s/p drainage
  • 2. Cardiac Tamponade Compression of all cardiac chambers due to increased pericardial pressure Pericardium has some compliance with increased pressure, but once that is exceeded it begins to impair diastolic compliance, reducing cardiac filling Much of the pressure is transmitted to the Rt Vent/Atrium (lower pressure systems) which causes which causes bulging of interventricular septum and decreased Lt ventricular compliance and filling
  • 3. Pericardial Effusion Pericardium typically has 20-50 ml of fluid Acuity of fluid accumulation plays a large role in pericardial compliance  Rapid accumulation (trauma) gives pericardium no time to adjust, therefore a small amount of fluid can cause tamponade  Slow accumulation allows pericardial compliance to increase allowing a larger volume of fluid into sac  However, when pericardial pressures > Rt ventricular pressure tamponade physiology can occur
  • 4. Causes of Pericardial Tamponade Malignancy HIV infection Infection - Viral, bacterial (tuberculosis), fungal Drugs - Hydralazine, procainamide, isoniazid, minoxidil Postcoronary intervention (ie, coronary dissection and perforation) Trauma Cardiovascular surgery (postoperative pericarditis) Postmyocardial infarction (free wall ventricular rupture, Dressler syndrome) Connective tissue diseases - Systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis Radiation therapy Iatrogenic - After sternal biopsy, transvenous pacemaker lead implantation, pericardiocentesis, or central line insertion Uremia Idiopathic pericarditis Complication of surgery at the esophagogastric junction such as antireflux surgery Pneumopericardium (due to mechanical ventilation or gastropericardial fistula)
  • 5. Symptoms Dyspnea, tachycardia, tachypnea Cold, clammy extremities Malignancy – weight loss, fatigue, anorexia Chest pain – pericarditis, MI Joint pain – connective tissue Renal failure – uremia Medications – drug related lupus Recent procedure – pacemaker, central line TB – night sweats, fever Radiation – cancer history
  • 6. Physical Exam Findings Beck’s Triad – JVD, hypotension, diminished heart sounds Hepatomegaly Evidence of chest wall trauma Pulsus paradoxsus > 12 mm Hg Kussmaul sign - paradoxical increase in venous distention and pressure during inspiration Abolished y descent
  • 7. Diagnosis EKG – low voltage, sinus tach, PR depression, electrical alternans
  • 8. Diagnosis CXR  enlarge cardiac silhouette, water bottle shaped heart
  • 9. Diagnosis Echocardiogram (tamponade is clinical diagnosis)  Pericardial effusion  Early diastolic collapse of the right ventricular free wall  Late diastolic compression/collapse of the right atrium  Swinging of the heart in its sac  LV pseudohypertrophy
  • 10. Diagnosis Rt Heart Catheterization  If patient is stable and diagnosis is in doubt can perform a Rt heart catheterization to measure Rt sided pressures  In tamponade, near equalization (within 5 mm Hg) of the right atrial, right ventricular diastolic, pulmonary arterial diastolic, and pulmonary capillary wedge pressure  Rt atrial pressure tracings show abolished systolic y descent
  • 11. Treatment What to do while your waiting on CT Surgery…  Oxygen  Volume expansion with blood, plasma, or saline to maintain adequate intravascular volume  Bed rest with leg elevation  This may help increase venous return.  Inotropic drugs (i.e. dobutamine)  Choose inotropes that do not increase systemic vascular resistance while increasing cardiac output.
  • 12. Treatment Once CT Surgery or Cardiology arrives  Pericardiocentesis  can be fluoroscopically or TTE guided  Pericardial window  involves the surgical opening of a communication between the pericardial space and the intrapleural space Recurrent effusion  Pericardectomy  Pericardial-peritoneal shunt  Pericardiodesis - corticosteroids, tetracycline, or antineoplastic drugs can be instilled into the pericardial space sclerosing the pericardium
  • 13. Treatment No one shows up and cardiac arrest is called  Emergency subxiphoid percutaneous drainage  A 16- or 18-gauge needle is inserted at an angle of 30-45° to the skin, near the left xiphocostal angle, aiming towards the left shoulder  When performed emergently, this procedure is associated with a reported mortality rate of approximately 4% and a complication rate of 17%

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