Pericardial effusion and tamponade: Difference between revisions

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==Background==
==Background==
*Always consider in pt w/ PEA
*Always consider in patient with PEA
*Always consider in pt w/ myocardial stab wound (80% result in tamponade)
*Always consider in patient with penetrating trauma anywhere in the cardiac box (80% result in tamponade)
**GSW is less likely to result in tamponade b/c pericardial defect is larger
**Gun shot wounds are less likely to result in tamponade because pericardial defect is larger
*Pathophysiology
*Pathophysiology
**Increased pericardial pressure > decreased RV filling > decreased CO
**Increased pericardial pressure > decreased RV filling > decreased cardiac output


===Etiology===
===Etiology===
#Hemopericardium
*Hemopericardium
##Trauma
**Trauma
##Iatrogenic (misplaced central line)
**Iatrogenic (misplaced [[central line]])
##Bleeding diathesis
**Bleeding diathesis
##Ventricular rupture (post-MI)
**Ventricular rupture (post-MI)
#Non-hemopericardium
*Non-hemopericardium
##Cancer
**Cancer - most commonly lung, breast, prostate, or hematologic
##Pericarditis
***[[Melanoma]] has predilection for heart
###Infectious
***May be related to radiation, infection, chemotherapy
###Uremic (renal failure)
**[[Pericarditis]]
##HIV complications (infection, Kaposi sarcoma, lymphoma)
***Infectious
##SLE
***Uremic ([[renal failure]])
##Post-radiation
**[[HIV]] complications (infection, [[Kaposi sarcoma]], lymphoma)
##Myxedema
**[[SLE]] and other autoimmune or connective tissue disorders
**Post-radiation
**[[Myxedema]]


==Differential Diagnosis==
==Differential Diagnosis==
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==Clinical Features==
==Clinical Features==
*CP, SOB, fatigue
*[[Chest pain]], shortness of breath, cough, fatigue
*CHF-type appearance
*[[CHF]]-type appearance
*Narrow pulse pressure
*Narrow pulse pressure
*Friction rub
*Friction rub
*Beck's Triad (33% of pts)
*Pulsus paradoxus (dec in BP on inspiration)
*Beck's Triad (33% of patients)
**Hypotension, muffled heart sounds, JVD
**Hypotension, muffled heart sounds, JVD


==Diagnosis==
==Evaluation==
#[[Ultrasound: Cardiac|Ultrasound]]
===[[Cardiac ultrasound|Ultrasound]]===
##RV collapse, effusion
*Pericardial effusion
##5% false negative (usually b/c pericardium is decompressing into L chest)
**In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
###Be suspicious if pt has a left-sided pulmonary effusion
**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>
#ECG
Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982</ref>
##Tachycardia (bradycardia is ominous finding)
*Classical ultrasound findings
##Normal or low voltage
**Diastolic collapse of the right atrium (in atrial diastole)
##Electrical alternans
**Diastolic collapse of the right ventricle
#CXR
**Plethoric IVC
##Enlarged cardiac silhouette
*Evaluating systolic vs. diastolic phases with M-mode
#[[Pulsus Paradoxus]]
**Position in PSL view with M-mode line through where RV appears to collapse
##>10mmHg change in sys BP on inspiration
**Allow M-mode line to pass through where the anterior MV hits the septum in diastole (much like evaluation of EPSS - see [[Formal echocardiography]])
[[File:RV_Collapse_M_mode.JPG|thumbnail]]
*Valvular pulsus parodoxus
**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
[[File:MV_inflow_variation.JPG|thumbnail]]


==Treatment==
===[[ECG]]===
#Hemorrhagic Tamponade
*Often normal
##[[Pericardiocentesis]]
*Tachycardia (bradycardia is ominous finding)
###Temporizing measure until thoracotomy can be performed
*Electrical alternans
##IVF to increase RV volume
*Low voltage
##Meds
**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>
###Pressors (temporizing)
**'''OR''' All precordial QRS amplitudes <10 mm or V1+V2+V3<30
###Avoid preload reducing meds (nitrates, diuretics)
 
#Non-hemorrhagic Tamponade
===[[CXR]]===
##[[Pericardiocentesis]]
*Enlarged cardiac silhouette
##Dialysis for pt w/ known renal failure
===[[Pulsus Paradoxus]]===
*>10mmHg change in systolic BP on inspiration
 
==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===
*[[Pericardiocentesis]]
*Dialysis for patients with known [[renal failure]]


==Disposition==
==Disposition==
#Admit with cardiology/CT surgery consult
*To OR if traumatic and hemodynamically unstable
*Admit with cardiology/CT surgery consult


==See Also==
==See Also==
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*[[Thoracic Trauma]]
*[[Thoracic Trauma]]
*[[Pericarditis]]
*[[Pericarditis]]
*[[Cardiac ultrasound]]


==Source==
==References==
Tintinalli
<references/>


[[Category:Cards]]
[[Category:Cardiology]]

Revision as of 23:06, 8 March 2019

Background

  • 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
  • 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
    • HIV complications (infection, Kaposi sarcoma, lymphoma)
    • SLE and other autoimmune or connective tissue disorders
    • Post-radiation
    • Myxedema

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Clinical Features

  • Chest pain, shortness of breath, cough, fatigue
  • CHF-type appearance
  • Narrow pulse pressure
  • Friction rub
  • Pulsus paradoxus (dec in BP on inspiration)
  • Beck's Triad (33% of patients)
    • Hypotension, muffled heart sounds, JVD

Evaluation

Ultrasound

  • 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.[1]
  • Classical ultrasound findings
    • Diastolic collapse of the right atrium (in atrial diastole)
    • Diastolic collapse of the right ventricle
    • Plethoric IVC
  • 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)
RV Collapse M mode.JPG
  • Valvular pulsus parodoxus
    • 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[2]
      • > 25%, likely tamponade physiology
      • > 40% for tricuspid inflow variation
      • Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients
MV inflow variation.JPG

ECG

  • Often normal
  • Tachycardia (bradycardia is ominous finding)
  • Electrical alternans
  • Low voltage
    • All limb lead QRS amplitudes <5 mm or I+II+III<15;[3]
    • OR All precordial QRS amplitudes <10 mm or V1+V2+V3<30

CXR

  • Enlarged cardiac silhouette

Pulsus Paradoxus

  • >10mmHg change in systolic BP on inspiration

Management

Hemorrhagic Tamponade

Non-hemorrhagic Tamponade

Disposition

  • To OR if traumatic and hemodynamically unstable
  • Admit with cardiology/CT surgery consult

See Also

References

  1. Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982
  2. 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.
  3. Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.