10.08.07 cardiac tamponade haag

8/12/2019 10.08.07 Cardiac Tamponade Haag

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Morning Report

10/8/07

Jason Haag


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Cardiac Tamponade 3 possible pericardial compression syndromes

Cardiac tamponade

accumulation of pericardial f luid under pressure and may beacute 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/pdrainage


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Cardiac Tamponade Compression of all cardiac chambers due to increased

pericardial pressure

Pericardium has some compliance with increasedpressure, but once that is exceeded it begins to impairdiastolic compliance, reducing cardiac filling

Much of the pressure is transmitted to the Rt

Vent/Atrium (lower pressure systems) which causeswhich causes bulging of interventricular septum anddecreased Lt ventricular compliance and filling


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Pericardial Effusion Pericardium typically has 20-50 ml of f luid

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 causetamponade

Slow accumulation allows pericardial compliance toincrease allowing a larger volume of fluid into sac

However, when pericardial pressures > Rt ventricularpressure tamponade physiology can occur


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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)


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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


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Physical Exam Findings Becks 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 inspirationAbolished y descent


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Diagnosis EKG low voltage, sinus tach, PR depression, electrical

alternans


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Diagnosis CXR

enlarge cardiac silhouette, water bottle shaped heart


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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


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Diagnosis Rt Heart Catheterization

If patient is stable and diagnosis is in doubt can performa Rt heart catheterization to measure Rt sided pressures

In tamponade, near equalization (within 5 mm Hg) ofthe right atrial, right ventricular diastolic, pulmonaryarterial diastolic, and pulmonary capillary wedgepressure

Rt atrial pressure tracings show abolished systolic ydescent


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TreatmentWhat to do while your waiting on CT Surgery

Oxygen

Volume expansion with blood, plasma, or saline tomaintain 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.


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Treatment Once CT Surgery or Cardiology arrives

Pericardiocentesis can be f luoroscopically 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 spacesclerosing the pericardium


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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 approximately4% and a complication rate of 17%


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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 andafter anti-inflammatory drug treatment. J Am Coll Cardiol 2001; 38:219.

Gillam, LD, Guyer, DE, Gibson, TC, et al. Hydrodynamic compression of theright atrium: A new echocardiographic sign of cardiac tamponade. Circulation1983; 68:294.

Fitchett, DH, Sniderman, AD. Inspiratory reduction in left heart filling as amechanism of pulsus paradoxus in cardiac tamponade. Can J Cardiol 1990;6:348
http://www.utdol.com/utd/content/abstract.do?topicKey=myoperic/13380&refNum=4http://www.utdol.com/utd/content/abstract.do?topicKey=myoperic/13380&refNum=4

10.08.07 cardiac tamponade haag

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