Morning Report 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 scarring and consequent loss of elasticity of the pericardial sac constrictive physiology with a coexisting pericardial effusion Chicken or egg? Elevated wedge and Rt sided pressures s/p drainage

Constrictive pericarditis

Effusive-constrictive pericarditis

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

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 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. Choose inotropes that do not increase systemic vascular resistance while increasing cardiac output.

Inotropic drugs (i.e. dobutamine)

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