Pericardial effusion and tamponade: Difference between revisions
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==Background== | ==Background== | ||
*Always consider in patient with PEA | [[File:Body Cavities Frontal view labeled 2.jpg|thumb|(d) Pericardial cavity, part of the inferior mediastinum, in relation to (a) superior mediastinum; (c) pleural cavities; and (e) diaphragm.]] | ||
*Always consider in patient with | [[File:2004 Heart Wall.jpg|thumb|Anatomy of the pericardium.]] | ||
** | [[File:PMC3518705 kcj-42-725-g005.png|thumb|Pericardial pressure-volume relationships in patients who have rapidly (left curve) and gradually (right curve) developed a pericardial effusion. In rapid accumulating effusion (left curve), even a small effusion volume can exceed the limit of parietal pericardial stretch and finally causes a steep rise in pressure. In contrast, slow accumulating effusion (right curve) requires a long time and a large volume to exceed the limit of pericardial stretch because of the activating compensatory mechanisms.]] | ||
*Always consider in patient with [[PEA]] | |||
*Always consider in patient with penetrating trauma anywhere in the cardiac box (80% result in tamponade) | |||
**[[Gun shot wounds]] are less likely to result in tamponade because pericardial defect is larger | |||
**Right ventricle is the most commonly injured chamber of the heart due to its anatomic location<ref>Gunay C, et al. Surgical challenges for urgent approach in penetrating heart injuries. Heart Surg Forum. 2007;10(6):E473-E477. doi:10.1532/HSF98.20071098</ref> | |||
*Pathophysiology | *Pathophysiology | ||
**Increased pericardial pressure > decreased RV filling > decreased | **Increased pericardial pressure > decreased RV filling > decreased cardiac output | ||
===Etiology=== | ===Etiology=== | ||
| Line 10: | Line 14: | ||
**Trauma | **Trauma | ||
**Iatrogenic (misplaced [[central line]]) | **Iatrogenic (misplaced [[central line]]) | ||
**Bleeding diathesis | **[[Coagulopathy|Bleeding diathesis]] | ||
**Ventricular rupture (post-MI) | **[[Myocardial rupture|Ventricular rupture]] (post-[[MI]]) | ||
*Non-hemopericardium | *Non-hemopericardium | ||
**Cancer - most commonly lung, breast | **Cancer - most commonly lung, breast, prostate, or hematologic | ||
***[[Melanoma]] has predilection for heart | ***[[Melanoma]] has predilection for heart | ||
***May be related to radiation, infection, chemotherapy | ***May be related to radiation, infection, chemotherapy | ||
| Line 19: | Line 23: | ||
***Infectious | ***Infectious | ||
***Uremic ([[renal failure]]) | ***Uremic ([[renal failure]]) | ||
**[[HIV]] complications (infection, [[Kaposi sarcoma]], lymphoma) | **[[HIV]] complications (infection, [[Kaposi sarcoma]], [[lymphoma]]) | ||
**[[SLE]] | **[[SLE]] and other autoimmune or [[connective tissue disorder]]s | ||
**Post-radiation | **Post-radiation | ||
**[[Myxedema]] | **[[Myxedema]] | ||
==Clinical Features== | ==Clinical Features== | ||
*[[Chest pain]], shortness of breath, cough, fatigue | *[[Chest pain]], shortness of breath, cough, fatigue | ||
*[[CHF]]-type appearance | *[[CHF]]-type appearance | ||
*Tachycardia | |||
*Narrow pulse pressure | *Narrow pulse pressure | ||
*Friction rub | *Friction rub | ||
*Pulsus paradoxus (dec in BP on inspiration) | *Pulsus paradoxus (dec in BP on inspiration) | ||
*Beck's Triad (33% of patients) | *Beck's Triad (33% of patients) | ||
**Hypotension | **[[Hypotension]] | ||
**Muffled heart sounds | |||
**JVD | |||
==Differential Diagnosis== | |||
{{Template:Chest Pain DDX}} | |||
==Evaluation== | ==Evaluation== | ||
===[[Pulsus Paradoxus]]=== | |||
*>10mmHg change in systolic BP on inspiration | |||
===[[CXR]]=== | |||
[[File:Massivepericarialeffusion.png|thumb|Massive pericardial effusion on chest x-ray]] | |||
*Enlarged cardiac silhouette | |||
===[[ECG]]=== | |||
[[File:Pericardial effusion with tamponade.png|thumb|Sinus tachycardia with low QRS voltage and electrical alternans]] | |||
*Often normal | |||
*[[Tachycardia]] (bradycardia is ominous finding) | |||
*Electrical alternans | |||
*Low voltage | |||
**All limb lead QRS amplitudes <5 mm or I+II+III<15;<ref>Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.</ref> | |||
**'''OR''' All precordial QRS amplitudes <10 mm or V1+V2+V3<30 | |||
===[[Cardiac ultrasound|Ultrasound]]=== | ===[[Cardiac ultrasound|Ultrasound]]=== | ||
[[File:Pericardial effusion with tamponade (cropped).gif|thumb|Transthoracic echo of pericardial effusion showing "swinging heart"]] | |||
[[File:PericardialeffusionUS.png|thumb|Pericardial effusion on ultrasound]] | |||
[[File:RV_Collapse_M_mode.JPG|thumbnail|Collapse M mode]] | |||
[[File:MV_inflow_variation.JPG|thumbnail|MV inflow variation]] | |||
*Pericardial effusion | *Pericardial effusion | ||
**In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise | **In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise | ||
*Diastolic collapse of the right atrium (in atrial diastole) | **Differentiate pericardial effusion from pleural effusion using the parasternal long axis view. Pericardial effusions will have an anechoic stripe between the left atrium and descending thoracic aorta. In a pleural effusion, the stripe will be seen behind the descending thoracic aorta.<ref>Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982</ref> | ||
*Diastolic collapse of the right ventricle | *Classical ultrasound findings | ||
*Plethoric IVC | **Diastolic collapse of the right atrium (in atrial diastole) | ||
*Valvular pulsus | **Diastolic collapse of the right ventricle | ||
**Plethoric IVC (highly sensitive but low specificity)<ref>What echocardiographic findings suggest a pericardial effusion is causing tamponade? Am J Emerg Med. 2019 Feb;37(2):321-326. doi: 10.1016/j.ajem.2018.11.004. Epub 2018 Nov 17.</ref> | |||
*Evaluating systolic vs. diastolic phases with M-mode | |||
**Position in PSL view with M-mode line through where RV appears to collapse | |||
**Allow M-mode line to pass through where the anterior MV hits the septum in diastole (much like evaluation of EPSS - see [[Formal echocardiography]]) | |||
**The period of time where the anterior leaflet of the mitral valve is open (and closest to the septum) is the period of diastole. Evaluate the anterior free wall of the right ventricle for collapse. The longer period of collapse during diastole is an indicator for advanced tamponade physiology | |||
*Valvular pulsus paradoxus | |||
**Obtain apical 4-chamber view, place doppler indicator in either MV or TV location | |||
**Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow | **Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow | ||
**MV inflow respiratory variation, difference from highest velocity to lowest, as a percentage of highest velocity<ref>Rajagopalan N, Garcia MJ, Rodriguez L, Murray RD, Apperson-Hansen C, Stugaard M, Thomas JD, and Klein AL. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol. 2001 Jan 1;87(1):86-94.</ref> | |||
***> 25%, likely tamponade physiology | |||
* | ***> 40% for tricuspid inflow variation | ||
* | ***Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients | ||
** | |||
* | |||
* | |||
==Management== | ==Management== | ||
| Line 66: | Line 92: | ||
*Medications | *Medications | ||
**[[Pressors]] (temporizing) | **[[Pressors]] (temporizing) | ||
**Avoid preload reducing medications ([[ | **Avoid preload reducing medications ([[nitroglycerin]], [[diuretics]]) | ||
===Non-hemorrhagic Tamponade=== | ===Non-hemorrhagic Tamponade=== | ||
*[[Pericardiocentesis]] | *[[IVF]] bolus of 500-1000 ml (patient is pre-load dependent) | ||
*[[Pericardiocentesis]] is definitive treatment | |||
*Dialysis for patients with known [[renal failure]] | *Dialysis for patients with known [[renal failure]] | ||
==Disposition== | ==Disposition== | ||
*To OR if traumatic and hemodynamically unstable | |||
*Admit with cardiology/CT surgery consult | *Admit with cardiology/CT surgery consult | ||
| Line 80: | Line 108: | ||
*[[Pericarditis]] | *[[Pericarditis]] | ||
*[[Cardiac ultrasound]] | *[[Cardiac ultrasound]] | ||
==External Links== | |||
*[https://emedicine.medscape.com/article/152083-overview#showall Medscape - Cardiac Tamponade] | |||
==References== | ==References== | ||
Latest revision as of 18:04, 12 April 2022
Background
Pericardial pressure-volume relationships in patients who have rapidly (left curve) and gradually (right curve) developed a pericardial effusion. In rapid accumulating effusion (left curve), even a small effusion volume can exceed the limit of parietal pericardial stretch and finally causes a steep rise in pressure. In contrast, slow accumulating effusion (right curve) requires a long time and a large volume to exceed the limit of pericardial stretch because of the activating compensatory mechanisms.
- Always consider in patient with PEA
- Always consider in patient with penetrating trauma anywhere in the cardiac box (80% result in tamponade)
- Gun shot wounds are less likely to result in tamponade because pericardial defect is larger
- Right ventricle is the most commonly injured chamber of the heart due to its anatomic location[1]
- Pathophysiology
- Increased pericardial pressure > decreased RV filling > decreased cardiac output
Etiology
- Hemopericardium
- Trauma
- Iatrogenic (misplaced central line)
- Bleeding diathesis
- Ventricular rupture (post-MI)
- Non-hemopericardium
- Cancer - most commonly lung, breast, prostate, or hematologic
- Melanoma has predilection for heart
- May be related to radiation, infection, chemotherapy
- Pericarditis
- Infectious
- Uremic (renal failure)
- HIV complications (infection, Kaposi sarcoma, lymphoma)
- SLE and other autoimmune or connective tissue disorders
- Post-radiation
- Myxedema
- Cancer - most commonly lung, breast, prostate, or hematologic
Clinical Features
- Chest pain, shortness of breath, cough, fatigue
- CHF-type appearance
- Tachycardia
- Narrow pulse pressure
- Friction rub
- Pulsus paradoxus (dec in BP on inspiration)
- Beck's Triad (33% of patients)
- Hypotension
- Muffled heart sounds
- JVD
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Evaluation
Pulsus Paradoxus
- >10mmHg change in systolic BP on inspiration
CXR
- Enlarged cardiac silhouette
ECG
- Often normal
- Tachycardia (bradycardia is ominous finding)
- Electrical alternans
- Low voltage
- All limb lead QRS amplitudes <5 mm or I+II+III<15;[2]
- OR All precordial QRS amplitudes <10 mm or V1+V2+V3<30
Ultrasound
.gif)
- Pericardial effusion
- In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
- Differentiate pericardial effusion from pleural effusion using the parasternal long axis view. Pericardial effusions will have an anechoic stripe between the left atrium and descending thoracic aorta. In a pleural effusion, the stripe will be seen behind the descending thoracic aorta.[3]
- Classical ultrasound findings
- Diastolic collapse of the right atrium (in atrial diastole)
- Diastolic collapse of the right ventricle
- Plethoric IVC (highly sensitive but low specificity)[4]
- Evaluating systolic vs. diastolic phases with M-mode
- Position in PSL view with M-mode line through where RV appears to collapse
- Allow M-mode line to pass through where the anterior MV hits the septum in diastole (much like evaluation of EPSS - see Formal echocardiography)
- The period of time where the anterior leaflet of the mitral valve is open (and closest to the septum) is the period of diastole. Evaluate the anterior free wall of the right ventricle for collapse. The longer period of collapse during diastole is an indicator for advanced tamponade physiology
- Valvular pulsus paradoxus
- Obtain apical 4-chamber view, place doppler indicator in either MV or TV location
- Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow
- MV inflow respiratory variation, difference from highest velocity to lowest, as a percentage of highest velocity[5]
- > 25%, likely tamponade physiology
- > 40% for tricuspid inflow variation
- Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients
Management
Hemorrhagic Tamponade
- Can occur if ECG read as STEMI/NSTEMI and heparin started
- Pericardiocentesis
- Temporizing measure until thoracotomy can be performed
- IVF to increase RV volume and maintain preload
- Medications
- Pressors (temporizing)
- Avoid preload reducing medications (nitroglycerin, diuretics)
Non-hemorrhagic Tamponade
- IVF bolus of 500-1000 ml (patient is pre-load dependent)
- Pericardiocentesis is definitive treatment
- Dialysis for patients with known renal failure
Disposition
- To OR if traumatic and hemodynamically unstable
- Admit with cardiology/CT surgery consult
See Also
External Links
References
- ↑ Gunay C, et al. Surgical challenges for urgent approach in penetrating heart injuries. Heart Surg Forum. 2007;10(6):E473-E477. doi:10.1532/HSF98.20071098
- ↑ Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.
- ↑ Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982
- ↑ What echocardiographic findings suggest a pericardial effusion is causing tamponade? Am J Emerg Med. 2019 Feb;37(2):321-326. doi: 10.1016/j.ajem.2018.11.004. Epub 2018 Nov 17.
- ↑ Rajagopalan N, Garcia MJ, Rodriguez L, Murray RD, Apperson-Hansen C, Stugaard M, Thomas JD, and Klein AL. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol. 2001 Jan 1;87(1):86-94.