Cardiac TamponadeCardiac Tamponade

Cardiac TamponadeCardiac Tamponade

Normal amt of pericardial fluid = 20-50 mLNormal amt of pericardial fluid = 20-50 mL

Tamponade occurs when lg or rapidly formed Tamponade occurs when lg or rapidly formed effusions effusions inc’d pressure in the pericardial inc’d pressure in the pericardial space throughout the cardiac cyclespace throughout the cardiac cycle

During inspiration, RV volume inc’s & in During inspiration, RV volume inc’s & in tamponade, the RV is unable to expand into the tamponade, the RV is unable to expand into the maximally stretched pericardium maximally stretched pericardium L-ward L-ward bulging of the interventricular septum bulging of the interventricular septum dec’d dec’d LVEDV LVEDV dec’d cardiac output & dec’d SBP dec’d cardiac output & dec’d SBP during inspirationduring inspiration

Etiology of Cardiac TamponadeEtiology of Cardiac Tamponade HIV, bacterial (incl mycobacterial), viral, fungalHIV, bacterial (incl mycobacterial), viral, fungal

CA - Esp lung, breast, Hodgkin’s, mesotheliomaCA - Esp lung, breast, Hodgkin’s, mesothelioma

Radiation txRadiation tx

Meds - Hydralazine, Procainamide, INH, MinoxidilMeds - Hydralazine, Procainamide, INH, Minoxidil

Post-MI (free wall ventricular rupture, Dressler’s syndrome)Post-MI (free wall ventricular rupture, Dressler’s syndrome)

Connective tissue dzs – SLE, RA, DermatomyositisConnective tissue dzs – SLE, RA, Dermatomyositis

UremiaUremia

TraumaTrauma

Iatrogenic – (eg, from TLC / PA Cath / TV pacemaker insertion, Iatrogenic – (eg, from TLC / PA Cath / TV pacemaker insertion, coronary dissection & perforation, sternal bx, pericardiocentesis, GE coronary dissection & perforation, sternal bx, pericardiocentesis, GE jnx surgeries)jnx surgeries)

Other - Pneumopericardium (d/t mech ventilation or gastropericardial Other - Pneumopericardium (d/t mech ventilation or gastropericardial fistula), Pleural effusionsfistula), Pleural effusions

Idiopathic Idiopathic

Clinical PresentationClinical Presentation

SxsSxs Chest Pain, dyspnea, near-syncopeChest Pain, dyspnea, near-syncope Generally more comfortable sitting forwardGenerally more comfortable sitting forward Sxs c/w the underlying cause of tamponadeSxs c/w the underlying cause of tamponade

Physical ExamPhysical Exam Beck’s Triad - Elev’d JVP, hypotension, dec’d heart soundsBeck’s Triad - Elev’d JVP, hypotension, dec’d heart sounds

JVP w/ preserved x descent and dampened or absent y descentJVP w/ preserved x descent and dampened or absent y descent Generally w/ narrow pulse pressureGenerally w/ narrow pulse pressure

Tachycardia, other signs of HF (tachypnea, diaphoresis, cool Tachycardia, other signs of HF (tachypnea, diaphoresis, cool extremities, cyanosis, etc)extremities, cyanosis, etc)

Pulsus paradoxusPulsus paradoxus Dec’d or absent cardiac impulseDec’d or absent cardiac impulse +/- Friction rub+/- Friction rub

Pulsus “Paradoxus”Pulsus “Paradoxus”

Dec in SBP > 10-12 Dec in SBP > 10-12 mmHg w/ inspirationmmHg w/ inspiration

Can also occur in pts w/ Can also occur in pts w/ COPD, pulm dz, PTX, COPD, pulm dz, PTX, severe asthmasevere asthma

Can have tamponade Can have tamponade w/o pulsus paradoxusw/o pulsus paradoxus In pts w/ pre-existing In pts w/ pre-existing

elev’s in diastolic elev’s in diastolic pressures and/or pressures and/or volume (eg, LV dysfnx, volume (eg, LV dysfnx, AI and ASD)AI and ASD)

DiagnosisDiagnosis

Tamponade is a Clinical DiagnosisTamponade is a Clinical Diagnosis

Other Detection MethodsOther Detection Methods EKGEKG

CXRCXR

TTETTE

R Heart CathR Heart Cath

CT, MRICT, MRI

EKG FindingsEKG Findings

Common FindingsCommon Findings Sinus tachycardiaSinus tachycardia Non-specific ST segment and T wave changesNon-specific ST segment and T wave changes Changes assoc’d w/ acute pericarditis (incl diffuse STE & Changes assoc’d w/ acute pericarditis (incl diffuse STE &

PR depression) PR depression)

Other FindingsOther Findings Dec’d voltage (non-specific and can also be d/t Dec’d voltage (non-specific and can also be d/t

emphysema, infiltrative myocardial dz, PTX, etc) emphysema, infiltrative myocardial dz, PTX, etc) Electrical alternans (specific but relatively insensitive for Electrical alternans (specific but relatively insensitive for

lg effusions)lg effusions) 2/2 anterior-posterior swinging of the heart w/ each beat 2/2 anterior-posterior swinging of the heart w/ each beat Best seen in leads V2 to V4 Best seen in leads V2 to V4

Combined P wave and QRS complex alternation (specific Combined P wave and QRS complex alternation (specific for cardiac tamponade) for cardiac tamponade)

EKG FindingsEKG Findings

CXR FindingsCXR Findings

Sudden inc in size of Sudden inc in size of cardiac silhouette w/o cardiac silhouette w/o specific chamber specific chamber enlargementenlargement

Effacement of the Effacement of the normal cardiac bordersnormal cardiac borders

Development of a Development of a “flask” or “H2O-bottle” “flask” or “H2O-bottle” shaped heartshaped heart

Lateral CXR Lateral CXR Findings Findings

May have (+) fat pad May have (+) fat pad signsign Separation of mediastinal Separation of mediastinal

/ retrosternal fat and / retrosternal fat and epicardial fat by > 2 mmepicardial fat by > 2 mm

TTETTE Test of choice for rapid assessment of pericardial effusions, but Test of choice for rapid assessment of pericardial effusions, but

these findings are often absent in pts w/ pulm HTN or RVHthese findings are often absent in pts w/ pulm HTN or RVH Characteristic FindingsCharacteristic Findings

Pericardial effusion Pericardial effusion Size often correlates w/ risk of tamponade but not alwaysSize often correlates w/ risk of tamponade but not always

End-diastolic chamber collapse End-diastolic chamber collapse RV expiratory collapse in early diastole (low sens, high spec)RV expiratory collapse in early diastole (low sens, high spec) RA expiratory collapse in late diastole (high spec if inward movement lasts RA expiratory collapse in late diastole (high spec if inward movement lasts

> 30% of cardiac cycle) > 30% of cardiac cycle) LA collapse (present in ~ 25%, highly spec)LA collapse (present in ~ 25%, highly spec)

Respiratory variation in transvalvular velocities during passive diastolic Respiratory variation in transvalvular velocities during passive diastolic filling. filling.

Transmitral resp varn > 25% transtricuspid varn > 50% are char of Transmitral resp varn > 25% transtricuspid varn > 50% are char of tamponadetamponade.   .   

IVC dilated & fails to collapse w/ inspiration (reflects elev’d CVP) IVC dilated & fails to collapse w/ inspiration (reflects elev’d CVP) Small cardiac chambersSmall cardiac chambers Swinging of the heart anteroposteriorly w/in the pericardial effusionSwinging of the heart anteroposteriorly w/in the pericardial effusion Reciprocal size changes w/ respiration b/w RV & LV & their valvesReciprocal size changes w/ respiration b/w RV & LV & their valves

TTE w/ Large Pericardial EffusionTTE w/ Large Pericardial Effusion

R Heart CathR Heart Cath Near equalization Near equalization

(w/in 5 mm Hg) (w/in 5 mm Hg) of the RA, RV, of the RA, RV, PCWP, RV PCWP, RV diastolic, & LV diastolic, & LV diastolic diastolic pressurespressures

RA pressure RA pressure tracings show tracings show diminshed diminshed systolic systolic yy descent descent

Tx of Cardiac TamponadeTx of Cardiac Tamponade

If mild, can sometimes tx w/ medical If mild, can sometimes tx w/ medical mgmtmgmt Including 1 or more of the following: NSAIDs, Including 1 or more of the following: NSAIDs,

Colchcine, and/or steroids, depending on the Colchcine, and/or steroids, depending on the suspected cause. suspected cause.

Require very close monitoring, including w/ Require very close monitoring, including w/ serial TTEs and/or RHCserial TTEs and/or RHC

Tx of Cardiac TamponadeTx of Cardiac Tamponade

Most require urgent/emergent Most require urgent/emergent pericardiocentesispericardiocentesis

Closed pericardiocentesisClosed pericardiocentesis Generally in cath lab but can be at bedsideGenerally in cath lab but can be at bedside Subxiphoid approach under echo guidance is most common - Subxiphoid approach under echo guidance is most common -

minimizes risk & can assess completeness of fluid removalminimizes risk & can assess completeness of fluid removal Can alternatively use Fluoroscopic guidanceCan alternatively use Fluoroscopic guidance Pigtail catheter often left in placePigtail catheter often left in place

Open Pericardiocentesis in the OROpen Pericardiocentesis in the OR May be best for loculated effusions, effusions containing clots May be best for loculated effusions, effusions containing clots

or fibrinous material, and/or effusions that are borderline in or fibrinous material, and/or effusions that are borderline in size size

Allow for bx and creation of a pericardial window for Allow for bx and creation of a pericardial window for recurrent effusionsrecurrent effusions

Bedside pericardiocentesis if pt is in extremisBedside pericardiocentesis if pt is in extremis

Emergency Bedside Emergency Bedside PericardiocentesisPericardiocentesis

16- or 18-gauge 16- or 18-gauge needle inserted at needle inserted at angle of 30-45° to angle of 30-45° to the skin, the skin, near the near the left xiphocostal left xiphocostal angle, aiming angle, aiming toward the L toward the L shouldershoulder

Tx of Cardiac Tamponade – Other MeasuresTx of Cardiac Tamponade – Other Measures

IVFs, especially if hypovolemic or if diuretics IVFs, especially if hypovolemic or if diuretics were given for dx of HFwere given for dx of HF

Temporary inotropic support (Dobutamine, Temporary inotropic support (Dobutamine, Dopamine)Dopamine)

Serial echos after draining the fluidSerial echos after draining the fluid

Analysis of pericardial fluidAnalysis of pericardial fluid Only has a low yield in determining the etiology of Only has a low yield in determining the etiology of

pericardial dzpericardial dz Can send for specific gravity, pH, glc, LDH, protein, Can send for specific gravity, pH, glc, LDH, protein,

cell count, cytology, staining & Cx for bacteria, cell count, cytology, staining & Cx for bacteria, fungi, & TB). fungi, & TB).

Tx of Recurrent EffusionsTx of Recurrent Effusions

PericardectomyPericardectomy

Pericardial-peritoneal shuntPericardial-peritoneal shunt

Pericardiodesis - Steroids, tetracycline, or Pericardiodesis - Steroids, tetracycline, or anti-neoplastic drugs administered into anti-neoplastic drugs administered into the pericardial space the pericardial space sclerosis of the sclerosis of the pericardiumpericardium

ReferencesReferences Spodick, DH. Acute cardiac tamponade. N Engl J Med 2003; Spodick, DH. Acute cardiac tamponade. N Engl J Med 2003;

349:684.349:684. Internet Journal of Anesthesiology 2001: Cardiac Tamponade Internet Journal of Anesthesiology 2001: Cardiac Tamponade

Secondary To Suppurative Pericarditis. A Case Report And Review Secondary To Suppurative Pericarditis. A Case Report And Review Of The Literature Of The Literature

Troughton, RW, Asher, CR, Klein, AL. Pericarditis. Lancet 2004; Troughton, RW, Asher, CR, Klein, AL. Pericarditis. Lancet 2004; 363:717. 363:717.

Reddy, PS, Curtiss, EI, O'Toole, JD, Shaver, JA. Cardiac tamponade: Reddy, PS, Curtiss, EI, O'Toole, JD, Shaver, JA. Cardiac tamponade: hemodynamic observations in man. Circulation 1978; 58:265.hemodynamic observations in man. Circulation 1978; 58:265.

Roy, CL, et al. Does this patient with a pericardial effusion have Roy, CL, et al. Does this patient with a pericardial effusion have cardiac tamponade. NEJM 2007; 297(16):1810-1818cardiac tamponade. NEJM 2007; 297(16):1810-1818

MD Consult BooksMD Consult Books Libby – Braunwald’s Heart DiseaseLibby – Braunwald’s Heart Disease Roberts – Clinical Procedures in Emergency MedicineRoberts – Clinical Procedures in Emergency Medicine Adam – Grainger & Allison’s Diagnostic RadiologyAdam – Grainger & Allison’s Diagnostic Radiology Goldman - Cecil MedicineGoldman - Cecil Medicine

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