7.27.09 burkhart tamponade

8/10/2019 7.27.09 Burkhart Tamponade

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Cardiac TamponadeCardiac Tamponade


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Cardiac TamponadeCardiac Tamponade

Normal amt of pericardial fluid = 20-50 mLNormal amt of pericardial fluid = 20-50 mL

Tamponade occurs when lg or rapidly formedTamponade occurs when lg or rapidly formedeffusionseffusions incd pressure in the pericardial spaceincd pressure in the pericardial spacethroughout the cardiac cyclethroughout the cardiac cycle

During inspiration !" #olume incs $ in tamponadeDuring inspiration !" #olume incs $ in tamponade

the !" is una%le to e&pand into the ma&imallythe !" is una%le to e&pand into the ma&imallystretched pericardiumstretched pericardium L-ward %ulging of theL-ward %ulging of theinter#entricular septuminter#entricular septum decd L"'D"decd L"'D" decddecdcardiac output $ decd ()* during inspirationcardiac output $ decd ()* during inspiration


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'tiology of Cardiac Tamponade'tiology of Cardiac Tamponade +," %acterial incl myco%acterial. #iral fungal+," %acterial incl myco%acterial. #iral fungal

C/ - 'sp lung %reast +odgins mesotheliomaC/ - 'sp lung %reast +odgins mesothelioma

!adiation t&!adiation t&

1eds - +ydralaine *rocainamide ,N+ 1ino&idil1eds - +ydralaine *rocainamide ,N+ 1ino&idil

*ost-1, free wall #entricular rupture Dresslers syndrome.*ost-1, free wall #entricular rupture Dresslers syndrome. Connecti#e tissue ds 3 (L' !/ DermatomyositisConnecti#e tissue ds 3 (L' !/ Dermatomyositis

4remia4remia

TraumaTrauma

,atrogenic 3 eg from TLC */ Cath T" pacemaer insertion coronary,atrogenic 3 eg from TLC */ Cath T" pacemaer insertion coronarydissection $ perforation sternal %& pericardiocentesis 6' 7n& surgeries.dissection $ perforation sternal %& pericardiocentesis 6' 7n& surgeries.

8ther - *neumopericardium dt mech #entilation or gastropericardial8ther - *neumopericardium dt mech #entilation or gastropericardialfistula. *leural effusionsfistula. *leural effusions

,diopathic,diopathic


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Clinical *resentationClinical *resentation

(&s(&s Chest *ain dyspnea near-syncopeChest *ain dyspnea near-syncope 6enerally more comforta%le sitting forward6enerally more comforta%le sitting forward (&s cw the underlying cause of tamponade(&s cw the underlying cause of tamponade

*hysical '&am*hysical '&am )ecs Triad - 'le#d 9"* hypotension decd heart sounds)ecs Triad - 'le#d 9"* hypotension decd heart sounds

9"* w preser#ed & descent and dampened or a%sent y descent9"* w preser#ed & descent and dampened or a%sent y descent 6enerally w narrow pulse pressure6enerally w narrow pulse pressure

Tachycardia other signs of +: tachypnea diaphoresis coolTachycardia other signs of +: tachypnea diaphoresis coole&tremities cyanosis etc.e&tremities cyanosis etc.

*ulsus parado&us*ulsus parado&us Decd or a%sent cardiac impulseDecd or a%sent cardiac impulse ;- :riction ru%;- :riction ru%


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*ulsus ?0-?2 mm+gw inspirationw inspiration

Can also occur in pts wCan also occur in pts w

C8*D pulm d *T@C8*D pulm d *T@se#ere asthmase#ere asthma

Can ha#e tamponadeCan ha#e tamponade

wo pulsus parado&uswo pulsus parado&us ,n pts w pre-e&isting,n pts w pre-e&isting

ele#s in diastolicele#s in diastolicpressures andor #olumepressures andor #olumeeg L" dysfn& /, andeg L" dysfn& /, and

/(D./(D.


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DiagnosisDiagnosis

Tamponade is a Clinical DiagnosisTamponade is a Clinical Diagnosis

8ther Detection 1ethods8ther Detection 1ethods 'A6'A6

C@!C@!

TT'TT'

! +eart Cath! +eart Cath

CT 1!,CT 1!,


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'A6 :indings'A6 :indings

Common :indingsCommon :indings (inus tachycardia(inus tachycardia Non-specific (T segment and T wa#e changesNon-specific (T segment and T wa#e changes Changes assocd w acute pericarditis incl diffuse (T' $ *!Changes assocd w acute pericarditis incl diffuse (T' $ *!

depression.depression.

8ther :indings8ther :indings Decd #oltage non-specific and can also %e dt emphysemaDecd #oltage non-specific and can also %e dt emphysema

infiltrati#e myocardial d *T@ etc.infiltrati#e myocardial d *T@ etc.

'lectrical alternans specific %ut relati#ely insensiti#e for lg'lectrical alternans specific %ut relati#ely insensiti#e for lgeffusions.effusions. 22 anterior-posterior swinging of the heart w each %eat22 anterior-posterior swinging of the heart w each %eat )est seen in leads "2 to "B)est seen in leads "2 to "B

Com%ined * wa#e and !( comple& alternation specific forCom%ined * wa#e and !( comple& alternation specific for

cardiac tamponade.cardiac tamponade.


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'A6 :indings'A6 :indings


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C@! :indingsC@! :indings

(udden inc in sie of(udden inc in sie ofcardiac silhouette wocardiac silhouette wospecific cham%erspecific cham%erenlargementenlargement

'ffacement of the'ffacement of thenormal cardiac %ordersnormal cardiac %orders

De#elopment of a


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Lateral C@! :indingsLateral C@! :indings

1ay ha#e ;. fat pad sign1ay ha#e ;. fat pad sign (eparation of mediastinal (eparation of mediastinal

retrosternal fat andretrosternal fat andepicardial fat %y > 2 mmepicardial fat %y > 2 mm
http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow112compwitharrows.jpg


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TT'TT' Test of choice for rapid assessment of pericardial effusions %ut theseTest of choice for rapid assessment of pericardial effusions %ut these

findings are often a%sent in pts w pulm +TN or !"+findings are often a%sent in pts w pulm +TN or !"+ Characteristic FindingsCharacteristic Findings

Pericardial effusionPericardial effusion Size often correlates w/ risk of tamponade but not alwaysSize often correlates w/ risk of tamponade but not always

End-diastolic chamber collapseEnd-diastolic chamber collapse !" e&piratory collapse in early diastole low sens high spec.!" e&piratory collapse in early diastole low sens high spec. !/ e&piratory collapse in late diastole high spec if inward mo#ement lasts > 0E!/ e&piratory collapse in late diastole high spec if inward mo#ement lasts > 0Eof cardiac cycle.of cardiac cycle. L/ collapse present in F 25E highly spec.L/ collapse present in F 25E highly spec.

!espiratory #ariation in trans#al#ular #elocities during passi#e diastolic!espiratory #ariation in trans#al#ular #elocities during passi#e diastolicfillingGfillingG Transmitral resp #arn > 25E transtricuspid #arn > 50E are char ofTransmitral resp #arn > 25E transtricuspid #arn > 50E are char of tamponadetamponadeGG

,"C dilated $ fails to collapse w inspiration reflects ele#d C"*.,"C dilated $ fails to collapse w inspiration reflects ele#d C"*. (mall cardiac cham%ers(mall cardiac cham%ers (winging of the heart anteroposteriorly win the pericardial effusion(winging of the heart anteroposteriorly win the pericardial effusion !eciprocal sie changes w respiration %w !" $ L" $ their #al#es!eciprocal sie changes w respiration %w !" $ L" $ their #al#es


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TT' w Large *ericardial 'ffusionTT' w Large *ericardial 'ffusion


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! +eart Cath! +eart Cath

Near eIualiationNear eIualiationwin 5 mm +g. ofwin 5 mm +g. ofthe !/ !" *CJ*the !/ !" *CJ*!" diastolic $ L"!" diastolic $ L"

diastolic pressuresdiastolic pressures

!/ pressure!/ pressure

tracings showtracings showdiminshed systolicdiminshed systolicyydescentdescent


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T& of Cardiac TamponadeT& of Cardiac Tamponade

,f mild can sometimes t& w medical mgmt,f mild can sometimes t& w medical mgmt ,ncluding ? or more of the followingK N(/,Ds,ncluding ? or more of the followingK N(/,Ds

Colchcine andor steroids depending on theColchcine andor steroids depending on the

suspected causeGsuspected causeG !eIuire #ery close monitoring including w serial!eIuire #ery close monitoring including w serial

TT's andor !+CTT's andor !+C


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T& of Cardiac TamponadeT& of Cardiac Tamponade

1ost reIuire urgentemergent pericardiocentesis1ost reIuire urgentemergent pericardiocentesis Closed pericardiocentesisClosed pericardiocentesis 6enerally in cath la% %ut can %e at %edside6enerally in cath la% %ut can %e at %edside (u%&iphoid approach under echo guidance is most common -(u%&iphoid approach under echo guidance is most common -

minimies ris $ can assess completeness of fluid remo#alminimies ris $ can assess completeness of fluid remo#al Can alternati#ely use :luoroscopic guidanceCan alternati#ely use :luoroscopic guidance *igtail catheter often left in place*igtail catheter often left in place

8pen *ericardiocentesis in the 8!8pen *ericardiocentesis in the 8! 1ay %e %est for loculated effusions effusions containing clots or1ay %e %est for loculated effusions effusions containing clots orfi%rinous material andor effusions that are %orderline in siefi%rinous material andor effusions that are %orderline in sie /llow for %& and creation of a pericardial window for recurrent/llow for %& and creation of a pericardial window for recurrent

effusionseffusions

)edside pericardiocentesis if pt is in e&tremis)edside pericardiocentesis if pt is in e&tremis


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'mergency )edside *ericardiocentesis'mergency )edside *ericardiocentesis

?- or ?M-gauge?- or ?M-gaugeneedle inserted atneedle inserted atangle of 0-B5 toangle of 0-B5 tothe sinthe sin near thenear the

left &iphocostalleft &iphocostalangle aiming towardangle aiming towardthe L shoulderthe L shoulder


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T& of Cardiac Tamponade 3 8ther 1easuresT& of Cardiac Tamponade 3 8ther 1easures

,":s especially if hypo#olemic or if diuretics were,":s especially if hypo#olemic or if diuretics weregi#en for d& of +:gi#en for d& of +:

Temporary inotropic support Do%utamineTemporary inotropic support Do%utamineDopamine.Dopamine.

(erial echos after draining the fluid(erial echos after draining the fluid

/nalysis of pericardial fluid/nalysis of pericardial fluid 8nly has a low yield in determining the etiology of8nly has a low yield in determining the etiology of

pericardial dpericardial d Can send for specific gra#ity p+ glc LD+ protein cellCan send for specific gra#ity p+ glc LD+ protein cell

count cytology staining $ C& for %acteria fungi $ T).Gcount cytology staining $ C& for %acteria fungi $ T).G


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T& of !ecurrent 'ffusionsT& of !ecurrent 'ffusions

*ericardectomy*ericardectomy

*ericardial-peritoneal shunt*ericardial-peritoneal shunt

*ericardiodesis - (teroids tetracycline or*ericardiodesis - (teroids tetracycline oranti-neoplastic drugs administered into theanti-neoplastic drugs administered into the

pericardial spacepericardial space

sclerosis of thesclerosis of the

pericardiumpericardium


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!eferences!eferences (podic D+G /cute cardiac tamponadeG N 'ngl 9 1ed 200O BPKMBG(podic D+G /cute cardiac tamponadeG N 'ngl 9 1ed 200O BPKMBG ,nternet 9ournal of /nesthesiology 200?K Cardiac Tamponade (econdary,nternet 9ournal of /nesthesiology 200?K Cardiac Tamponade (econdary

To (uppurati#e *ericarditisG / Case !eport /nd !e#iew 8f TheTo (uppurati#e *ericarditisG / Case !eport /nd !e#iew 8f TheLiteratureLiterature

Troughton !J /sher C! Alein /LG *ericarditisG Lancet 200BO KQ?QGTroughton !J /sher C! Alein /LG *ericarditisG Lancet 200BO KQ?QG

!eddy *( Curtiss ', 8RToole 9D (ha#er 9/G Cardiac tamponadeK!eddy *( Curtiss ', 8RToole 9D (ha#er 9/G Cardiac tamponadeKhemodynamic o%ser#ations in manG Circulation ?PQMO 5MK25Ghemodynamic o%ser#ations in manG Circulation ?PQMO 5MK25G !oy CL et alG Does this patient with a pericardial effusion ha#e cardiac!oy CL et alG Does this patient with a pericardial effusion ha#e cardiac

tamponadeG N'91 200QO 2PQ?.K?M?0-?M?MtamponadeG N'91 200QO 2PQ?.K?M?0-?M?M 1D Consult )oos1D Consult )oos

Li%%y 3 )raunwalds +eart DiseaseLi%%y 3 )raunwalds +eart Disease !o%erts 3 Clinical *rocedures in 'mergency 1edicine!o%erts 3 Clinical *rocedures in 'mergency 1edicine /dam 3 6rainger $ /llisons Diagnostic !adiology/dam 3 6rainger $ /llisons Diagnostic !adiology 6oldman - Cecil 1edicine6oldman - Cecil 1edicine

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7.27.09 burkhart tamponade

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