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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
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