10.08.07 Cardiac Tamponade Haag
10.08.07 Cardiac Tamponade Haag
10.08.07 Cardiac Tamponade Haag
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