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Discussant Slides

  1. 1. CPC #4 Edward K. Kasper, M.D. Chief of Clinical Cardiology Johns Hopkins Hospital
  2. 2. A 60 –year-old female <ul><li>Multiple risk factors for coronary artery disease on dialysis </li></ul><ul><li>Presents with hypoglycemia </li></ul><ul><li>Elevated troponin – ASA, heparin, BB, TNG </li></ul><ul><li>Probable UTI - gatifloxacin </li></ul><ul><li>Large pericardial effusion </li></ul><ul><li>Asystolic cardiac arrest and dies </li></ul>
  3. 3. Timeline of Events <ul><li>12/10 – ED, hyperkalemia, Hct 44%, started on gatifloxacin </li></ul><ul><li>12/11 – Medicine, BB, ASA, Heparin, nitrates, dialyzed, Hct 35% </li></ul><ul><li>12/12 – Dialysis, echo - large pericardial effusion, no tamponade </li></ul><ul><li>12/13 – Water bottle heart on CXR, asystolic at 5 AM </li></ul>
  4. 4. JAMA April 25, 2007
  5. 5. Causes of Pericardial Effusion <ul><li>Idiopathic </li></ul><ul><li>Infection (bacterial, viral, retroviral, fungal, parasitic, TB) </li></ul><ul><li>Trauma </li></ul><ul><li>Hemorrhage* (trauma, MI, Aortic rupture, heart surgery) </li></ul><ul><li>Cancer </li></ul><ul><li>Radiation therapy </li></ul><ul><li>Kidney failure </li></ul><ul><li>Autoimmune disorders (SLE, RA) </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Drugs (PCN, anticoagulants*) </li></ul>
  6. 6. Tamponade 3 10 20 X Normal Tamponade
  7. 7. Tamponade - Clinical Findings <ul><li>They look sick! </li></ul><ul><li>Tachypnea </li></ul><ul><li>Pale </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Cool extremities </li></ul><ul><li>Cyanosis </li></ul><ul><li>Confusion </li></ul><ul><li>Hypotension </li></ul><ul><li>Paradoxical pulse </li></ul><ul><li>Elevated JVP </li></ul><ul><li>Tachycardia </li></ul>
  8. 8. Cardiac Arrest <ul><li>CAD* </li></ul><ul><li>Cardiomyopathy </li></ul><ul><li>Myocarditis </li></ul><ul><li>Commotio cortis </li></ul><ul><li>Tamponade* </li></ul><ul><li>Embolism </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Hypovolemia </li></ul><ul><li>Hypoxia </li></ul><ul><li>Potassium (high, low) </li></ul><ul><li>Calcium (high) </li></ul><ul><li>Catecholamines </li></ul><ul><li>Hypothermia </li></ul><ul><li>Long QT </li></ul><ul><li>Electrocution </li></ul><ul><li>Drowning </li></ul>
  9. 9. Drug-Induced Long QT Syndrome <ul><li>Possible – gatifloxacin </li></ul><ul><li>www.arizonacert.org </li></ul>
  10. 10. Possible Hypotheses <ul><li>Silent myocardial infarction leading to cardiac rupture into pericardial space </li></ul><ul><li>Aortic rupture into pericardial space </li></ul><ul><li>Pericarditis (uremic) with heparin-induced bleeding into pericardium </li></ul><ul><li>Primary arrhythmic event </li></ul>
  11. 11. Correct Me If I’m Wrong!

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