10.08.07 Cardiac Tamponade Haag

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Morning Report

10/8/07
Jason Haag
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
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
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
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)
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
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
Diagnosis
EKG – low voltage, sinus tach, PR depression,
electrical alternans
Diagnosis
CXR
enlarge cardiac silhouette, water bottle shaped heart
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
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
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.
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
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%
References
 Spodick, DH. Acute cardiac tamponade. N Engl J Med 2003; 349:684.
 Chou, TC. Electrocardiography in Clinical Practice: Adults and Pediatrics, 4th
ed, WB Saunders, Philadelphia 1996
 Reydel, B, Spodick, DH. Frequency and significance of chamber collapses
during cardiac tamponade. Am Heart J 1990; 119:1160
 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.
 Bruch, C, Schmermund, A, Dagres, N, et al. Changes in QRS voltage in cardiac
tamponade and pericardial effusion: reversibility after pericardiocentesis and
after anti-inflammatory drug treatment. J Am Coll Cardiol 2001; 38:219.
 Gillam, LD, Guyer, DE, Gibson, TC, et al. Hydrodynamic compression of the
right atrium: A new echocardiographic sign of cardiac tamponade. Circulation
1983; 68:294.
 Fitchett, DH, Sniderman, AD. Inspiratory reduction in left heart filling as a
mechanism of pulsus paradoxus in cardiac tamponade. Can J Cardiol 1990;
6:348

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