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Cardiac Tamponade Cardiac Tamponade 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 HIV, bacterial (incl mycobacterial), viral, fungal CA - Esp lung, breast, Hodgkin’s, mesothelioma Radiation tx Meds - Hydralazine, Procainamide, INH, Minoxidil Post-MI (free wall ventricular rupture, Dressler’s syndrome) Connective tissue dzs – SLE, RA, Dermatomyositis Uremia Trauma 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 Sxs Chest Pain, dyspnea, near-syncope Generally more comfortable sitting forward Sxs c/w the underlying cause of tamponade Physical Exam Beck’s Triad - Elev’d JVP, hypotension, dec’d heart sounds 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” 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 In pts w/ pre-existing elev’s in diastolic pressures and/or volume (eg, LV dysfnx, AI and ASD) Diagnosis Tamponade is a Clinical Diagnosis Other Detection Methods EKG CXR TTE R Heart Cath CT, MRI EKG Findings Common Findings Sinus tachycardia Non-specific ST segment and T wave changes Changes assoc’d w/ acute pericarditis (incl diffuse STE & PR depression) Other Findings 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) 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 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 May have (+) fat pad sign Separation of mediastinal / retrosternal fat and epicardial fat by > 2 mm TTE Test of choice for rapid assessment of pericardial effusions, but these findings are often absent in pts w/ pulm HTN or RVH Characteristic Findings Pericardial effusion End-diastolic chamber collapse 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) Transmitral resp varn > 25% transtricuspid varn > 50% are char of tamponade. 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 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 If mild, can sometimes tx w/ medical mgmt 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 Most require urgent/emergent pericardiocentesis Closed pericardiocentesis Open Pericardiocentesis in the OR 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 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 IVFs, especially if hypovolemic or if diuretics were given for dx of HF Temporary inotropic support (Dobutamine, Dopamine) Serial echos after draining the fluid Analysis of pericardial fluid 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 Pericardectomy Pericardial-peritoneal shunt Pericardiodesis - Steroids, tetracycline, or anti-neoplastic drugs administered into the pericardial space sclerosis of the pericardium References 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 Troughton, RW, Asher, CR, Klein, AL. Pericarditis. Lancet 2004; 363:717. Reddy, PS, Curtiss, EI, O'Toole, JD, Shaver, JA. Cardiac tamponade: hemodynamic observations in man. Circulation 1978; 58:265. Roy, CL, et al. Does this patient with a pericardial effusion have cardiac tamponade. NEJM 2007; 297(16):1810-1818 MD Consult Books Libby – Braunwald’s Heart Disease Roberts – Clinical Procedures in Emergency Medicine Adam – Grainger & Allison’s Diagnostic Radiology Goldman - Cecil Medicine LearningRadiology.com