Pericardial effusion and tamponade: Difference between revisions

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*Always consider in patient with PEA
*Always consider in patient with PEA
*Always consider in patient with penetrating trauma anywhere in the cardiac box (80% result in tamponade)
*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
**[[Gun shot wounds]] are less likely to result in tamponade because pericardial defect is larger
*Pathophysiology
*Pathophysiology
**Increased pericardial pressure > decreased RV filling > decreased cardiac output
**Increased pericardial pressure > decreased RV filling > decreased cardiac output
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**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, prostate, or hematologic
**Cancer - most commonly lung, breast, prostate, or hematologic
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***Infectious
***Infectious
***Uremic ([[renal failure]])
***Uremic ([[renal failure]])
**[[HIV]] complications (infection, [[Kaposi sarcoma]], lymphoma)
**[[HIV]] complications (infection, [[Kaposi sarcoma]], [[lymphoma]])
**[[SLE]] and other autoimmune or connective tissue disorders
**[[SLE]] and other autoimmune or [[connective tissue disorder]]s
**Post-radiation
**Post-radiation
**[[Myxedema]]
**[[Myxedema]]
==Differential Diagnosis==
{{Template:Chest Pain DDX}}


==Clinical Features==
==Clinical Features==
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*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, muffled heart sounds, JVD
**[[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
**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>
**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>
Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982</ref>
*Classical ultrasound findings
*Classical ultrasound findings
**Diastolic collapse of the right atrium (in atrial diastole)
**Diastolic collapse of the right atrium (in atrial diastole)
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**Position in PSL view with M-mode line through where RV appears to collapse
**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]])
**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 paradoxus
*Valvular pulsus parodoxus
**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>
**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>
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***> 40% for tricuspid inflow variation
***> 40% for tricuspid inflow variation
***Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients
***Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients
[[File:MV_inflow_variation.JPG|thumbnail]]
===[[ECG]]===
*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
===[[CXR]]===
*Enlarged cardiac silhouette
===[[Pulsus Paradoxus]]===
*>10mmHg change in systolic BP on inspiration


==Management==
==Management==

Revision as of 16:23, 17 September 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

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)

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Evaluation

Pulsus Paradoxus

  • >10mmHg change in systolic BP on inspiration

CXR

Massive pericardial effusion on chest x-ray
  • Enlarged cardiac silhouette

ECG

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;[1]
    • OR All precordial QRS amplitudes <10 mm or V1+V2+V3<30

Ultrasound

Transthoracic echo of pericardial effusion showing "swinging heart"
Pericardial effusion on ultrasound
Collapse M mode
MV inflow variation
  • 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.[2]
  • 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)
  • Valvular pulsus paradoxus
    • 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[3]
      • > 25%, likely tamponade physiology
      • > 40% for tricuspid inflow variation
      • Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients

Management

Hemorrhagic Tamponade

Non-hemorrhagic Tamponade

Disposition

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

See Also

References

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