justin bowra critical care ultrasound course...us features of tamponade 1. is the patient shocked?...
TRANSCRIPT
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Pericardial tamponade
Justin Bowra
Critical Care Ultrasound Course
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Summary
Overview: diagnosing tamponadeScanning an effusion: US appearance, mimicsMeasuring the effusion?US signs of tamponadeShould I stick in a needle?Pericardiocentesis
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Overview: get your thinking right!
Effusion≠ Tamponade
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Tamponade is a clinical diagnosis
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Beck’s triad
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Shock, resistant to fluid Breathless, with clear chest Clinical suspicion of tamponade eg recent MI Ultrasound features?
How to diagnose tamponade
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US features of tamponade
1. Is the patient shocked?2. Is there stuff in the pericardium?3. Is the IVC distended?4. How big is the effusion?5. RV diastolic collapse?
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Is there stuff in the pericardium?
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Scanning a pericardial effusion
Either probe is fine (curved or sector) Either preset is fine (cardiac or abdominal) Try all available cardiac windows Subcostal is usually best (liver is a nice window)
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Pericardial fluid
Usually anechoic (dark)Usually surrounds heart
Usually seen better in systole
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Not always dark
Iso- or hyperechoic (clotted blood)
Heterogenous (clots, tumour, pus)
Not all fluid is black on US
Don't be fooled
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LV
Mirror image of LV
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Doesn’t always surround the heart
Localised effusions can occurEsp. after post cardiac surgery
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Not always pericardial fluid!
False positives for pericardial effusion:
Pericardial fat pad• Usually anterior to heart• Not quite anechoic
Pleural effusion• Not limited by pericardial space• Seen in left thorax as well
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False positives & negatives
False negatives• Clotted blood• Tumour• Localised effusions
(post cardiac surgery)
False positives• Pericardial fat pad• Pleural effusion
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Not sure if it’s pericardial fluid or a fat pad?
It’s 2am & everyone is looking at you.
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Not sure if it’s pericardial fluid or a fat pad?
It’s 2am & everyone is looking at you.
If you don’t like the question, change the question.
Is it pericardial fluid or fat pad?
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Not sure if it’s pericardial fluid or a fat pad?
It’s 2am & everyone is looking at you.
If you don’t like the question, change the question.
Is it pericardial fluid or fat pad? X
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Not sure if it’s pericardial fluid or a fat pad?
It’s 2am & everyone is looking at you.
If you don’t like the question, change the question.
Is it pericardial fluid or fat pad? XIs it a tamponade or can it wait? ✓
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US features of tamponade
1. Shocked patient2. Stuff in the pericardium3. Distended IVC4. Size of the effusion (not so much)5. RV diastolic collapse (hard to see)
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US features of tamponade
1. Shocked patient2. Stuff in the pericardium3. Distended IVC4. Size of the effusion (not so much)5. RV diastolic collapse (hard to see)
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US features of tamponade
1. Shocked patient2. Stuff in the pericardium3. Distended IVC4. Size of the effusion (not so much)5. RV diastolic collapse (hard to see)
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Is the IVC distended?
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Is this a tamponade?
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Is this a tamponade?
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How big is the effusion?
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How big is the effusion?
Not so important!
A small effusion can tamponade if it accumulates rapidly.
A large effusion might accumulate slowly.
Rarely, a small localised effusion can cause tamponade (eg post-valve surgery).
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But everyone loves to ask. So…
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A rough guide:
Just in systole = a tiny effusion Also in diastole = a bit larger Heart rocking = a massive effusion
But it still ain’t tamponade… unless patient is shocked!
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Test: pericardial effusion size
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Massive effusion: RV ‘squeezed’ (NB how can you tell this one is chronic?)
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Small effusion: doesn’t surround heart
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Moderate effusion: clotted blood from dissection
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LUNG HEART
PLEURAL FLUID
PERICARDIALFLUID
Moderate pericardial effusion AND pleural effusion
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Massive pericardial effusion (swinging heart)
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Finally…Is there RV diastolic collapse?
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Does the RV collapse in diastole?
RV is always anterior to LV RA/RV is a low pressure system In diastole, pressure falls further The pericardium is a tough fibrous sac Pericardial fluid that accumulates too fast for the
pericardium to stretch, then … Pericardial pressure > RA filling pressure Then pericardial pressure > RV filling pressure On US: ‘diastolic collapse’
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RV diastolic collapse
Tricky! We don’t use ECG leads We don’t usually play back the images slowly The easiest way to describe: ‘the RV is behaving
strangely in diastole’ ‘Someone’s jumping on the trampoline’ ‘Duh… somethin’ ain’t right!’
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RV diastolic collapse
Systole Diastole
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RV diastolic collapse?
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RV diastolic collapse?
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RV diastolic collapse?
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RV diastolic collapse
This is almost tamponade!But unless patient is shocked, tamponade is not present.
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Top tips
If in doubt: turn off the machine & be a doctor
Remember the 90% rule: you will be wrong 10% of the time. If this is a problem, don’t practise critical care medicine.
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SummaryIs the effusion causing a tamponade?
① Is the patient shocked? = the big question② Is the IVC distended? = also important③ How big is the effusion? = not as important④ (Is there RV diastolic collapse? = tricky)
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Should I stick in a needle?
This is a clinical decision
①YES- if shock + pericardial effusion + distended IVC②NO- if not shocked③NO- if needle won’t help (eg type A dissection)④PROBABLY NOT- if IVC is skinny and collapsing
If in doubt: turn off the machine & be a doctor
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1
Draining pericardial effusions
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Summary
Indication Technique Top tips
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Indications Tamponade
Effusion Compromised patient
Experienced operator … ideally
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Preparation
Consent, equipment Get the patient / machine / needle / probe in
the right position Sterile technique Team
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US machine
In line of sight [demo]
Assistant
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Probe
Cardiac probe: get the big picture 2 planes Scan thru resp cycle Check depth
No need to switch to linear probe Wastes time Worse at landmarks But can be comforting because likelier to show the
needle & catheter!
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Tips if using the cardiac probe
Pick the site with most pericardial fluid May not see the needle on screen (steep angle,
near field) Use needle/syringe with agitated saline: insert a
small amount: turbulence & microbubbles on screen
– If pericardial space 'lights up', you're in!– If RV lights up, pull out!
Pick the site with most pericardial fluid
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‘Pericardiocentesis – bubble confirmation’
http://www.youtube.com/watch?v=wGeS81cQNS0
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Best site for drainage?
Traditional: subcostal
What's wrong with this picture?
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Best site for drainage?
Best site depends on: Patient position Best window Greatest depth of pericardial fluid
A needle introduced subcostally will penetrate the liver!
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SUMMARY
If not shocked, there is no tamponade
It’s easier to image the IVC than the RV
Pericardiocentesis: often you won't see the needle on screen
– Advance needle slowly– Confirm placement confirmation by
reinjecting fluid or agitated saline
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Thanks to
Anjana AmarasekaraHenry Curtis
Julie-Anne GreensladeJosh Holden
Brendon Smith
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References
Rajesh Geria, M.D., RDMS. ACEP sonoguide, http://www.sonoguide.com/pericardiocentesis.html
Kaddoura S. Echo Made Easy, Churchill Livingstone
Pate JW et al. Diagnosis of pericardial effusion by echocardiography. Ann Surg. 1967 May; 165(5): 826–829.