cardiac tamponade - prof yogiarto, md, fiha.pdf
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
R. MOHAMMAD YOGIARTO
CARDIAC TAMPONADE
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INTRODUCTION
Claudius Galen (131-201 AD)
Richard Lower (1669)
Edmund Rose
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Introduction…
Cardiac tamponade is defined as an accumulationof fluid in the pericardial sac, creating an increasedpressure within the pericardial space that impairsthe ability of the heart to fill and to pump.
Decrease in stroke volume, cardiac output andsystemic perfusion leading to life-threatening organ
dysfunction.
Understanding the physiological changes producedby tamponade is essential to diagnosis andtreatment.
(Tsang et.al,1999;Ramos and Lily,2007; Winter,2012)
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EPIDEMIOLOGY
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ETIOLOGY
Malignancies
Septicaemia
Renal failure
pericarditis uremia
Drugs
Cyclosporine
Anticoagulants
Thrombolytics
(Tsang et.al,1999;Ramos and Lily,2007; Winter,2012)
Injury
Recent cardiac surgery
Indwellinginstrumentation
Blunt chest trauma Ventricle free wall rupture
Desection of Aneurismaaorta
Connective tissue disease
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PATOPHYSIOLOGY
Cardiac tamponade develops as a result of fluidaccumulation within the pericardial space
Increased intrapericardial pressure, progressivelimitation of ventricular diastolic filling, reduction of stroke volume and cardiac output
(Ramos and Lily, 2007; Sauleda J.S et al,2008; Le Winter et al,2012)
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IMPAIRED DIASTOLIC FILLING OF VENTRICLES
PERICARDIAL FLUID UNDER PRESSURE
CARDIAC TAMPONADE
PULMONARY
RALES
SYSTEMIC
VENOUS
CONGESTION
PULMONARY
VENOUS
CONGESTION
JUGULAR VENOUS
DISTENTION,
HEPATOMEGALY,
ASCITES, PERIPHERAL
EDEMA
ELEVATED VENOUSPRESSURES IMPAIRED STROKEVOLUME
DECREASED
CARDIAC OUTPUT
HYPOTENSION
REFLEX
TACHYCARDIA
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Types of tamponade
Acute tamponade
- Due to trauma, rupture of the heart or aorta or complication of aninvasive diagnostic or therapeutic intervention
- Sudden in onset
- Hypotension common
Subacute tamponade
- Pericardial fluid accumulates slowly
- Hypotension with a narrow pulse pressure, reflecting limited strokevolume. However, patients with preexisting hypertension may remainhypertensive due to increased sympathetic activity
( Spodick D.H, 2003)
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Types of tamponade….
Low pressure tamponade Severely hypovolemic (hemorrhage, hemodyalisis, or
overdiuresis)
intracardiac and pericardial diastolic pressures are only 6 to12 mmHg
fluid challenge usually elicits typical tamponade
hemodynamics
Regional tamponade
caused by a loculated, eccentric effusion
typical physical, hemodynamic, and echocardiographicsigns of tamponade may be absent
(Sauleda J.S et al.2008; Sauleda J.S et al.2006
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Physical Examination Findings
Hypotension with pulsus paradoxus ( decreased systolicblood pressure > 10 mmHg during inspiration whereasdiastolic blood pressure remains unchange )
Muffled heart sounds : suppressed heart sounds occur due to the muffling effects of the fluid surrounding the
heart
Elevated JVP
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Physical Examination Findings
Tachycardia
Pericardial friction rub: can be found in patient cardiactamponade due to pericarditis , characterized by scratchy andgrating sound tends to be louder during inspiration with thepatient leaning forward. Best heard in left lower sternal border
Tachipneu
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ELECTROCARDIOGRAM
Electricals alternans
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ELECTROCARDIOGRAM….
Common Findings
Sinus tachycardia
Non-specific ST segment and T wave changes
Changes associated with acute pericarditis (includediffuse ST Elevation & PR depression)
Other Findings Low voltage
Electrical alternans :beat to beat alterations in the QRScomplex swinging of the heart
Best seen in leads V2 to V4
Combined P wave and QRS complex alternation(specific for cardiac tamponade)
(Le Winter M.M, 2012)
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CHEST X-RAY FINDINGS
Enlarge cardiacsilhouet “ erlenmeyer
shape” with clear
lungs
Normal chest X-ray
Cardiomegaly
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ECHOCARDIOGRAPHY
2D and M-mode• RV diastolic collapse• RA collapse• Inferior Vena Cava (IVC)
plethora, dilatation and < 50 %reduction in the diameters of IVC during inspiration
• LA and very rarely LV collapse• Increased LV diastolic wall
thickness “pseudohypertrophy”
• “SWINGING HEART”
• Doppler study discloses marked
respiratory variation intransvalvular flow
(Tsang et al,1999, Spodick D.H, 2003;Feigenbaum et al,2006; Pande A.V, 2007;
Bulwer B.E, 2009)
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ECHOCARDIOGRAPHY
Confirm size of the pericardial effusion Small defined as < 10 mm in echo-free space in diastole
Moderate defined as 10-20 mm ( at least >= 10 mmposteriorly)
Large defined as >= 20 mm
Very large >= 20 mm and compression of the heart
Confirm location of the pericardial effusion
Rule out loculated effusions
Assist pericardiocentesis
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Ct scan
Focal atele
Large
EffusionCollapsed RV
Collapsed RV
a large pericardial
effusion
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DIAGNOSIS
Tamponade is a Clinical
Diagnosis
TRIAS BECK :
Hypotension with Pulsus
paradoxus
Elevated JVP
Muffled heart sounds
Other detection methods
:
EKG
CXR
Trans Thoracal
Echocardiography
CT, MRI
( Ramos Y and Lily L.S,2007; Le Winter et al.,2012; Hoit B.D, 2015)
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DIFFERENTIAL DIAGNOSIS
• Primary myocardial dysfunction meansthe heart is unable to produce anadequate cardiac output.
Cardiogenicshock
• Characteristic mill-wheel murmur, asplashing auscultatory sound due to thepresence of gas in the cardiac chambers
• this condition can be seen after penetrating
chest wall injury, rupture esophagus andbronchopericardial fistula
Pneumothorax
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DIFFERENTIAL DIAGNOSIS
• Caused by thickened pericardium impairingventricular diastolic fx. May mimic tamponade inthe absence of an effusion.
• In constrictive pericarditis miocardium is notcompresed until the the heart expanses to fill
pericardium during mid to late diastolic• Kusmaull sign- a paradoxical rise in JVP oninspiration in but not found in cardiac tamponade
Constrictivepericarditis
• Can cause shortness of breath ,hypotension, elevated JVP BUT NOT
pulsus paradoxus•
Pulmonary
embolism
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Management
European Society of Cardiology in Guidelines on theDiagnosis & Management of Pericardial Diseases-2004 :
Class 1:
Cardiac tamponade
Effusion > 20 mm in echocardiography ( diastole )
Suspected purulent or tuberculous pericardial effusion
Class II a:
Effusion 10-20 mm in echocardiography in diastole for diagnostic purposes other than purulent pericarditis or
tuberculosis ( pericardial fluid and tissue analyses,pericardioscopy, and epicardial / pericardial biopsy)
Suspected neoplastic pericardialeffusion
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Management………..
Class II b Effusions < 10 mm in echocardiography in
diastole for diagnostic purpose other thanpurulent, neoplastic or tuberculous pericarditis
Contraindications ( Class III )
Aortic disection
Relative contraindications include uncorrectedcoagulopathy, anticoagulant therapy,thrombocytopenia < 50.000/ mm3, small ,
posterior, and loculated effusions.
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Management….
IVF especialy if hypovolemia
Temporary inotropic support
Serial echo after draining fluid Analysis of pericardial fluid :
Specific gravity, PH, glucosa, LDH, protein, cellcount.cytology.
Staining and diagnosis for bacteria, fungi , TB
( Ramos Y and Lily,2007; Gumrukcougiu et al, 2011; Hoit BD ,2015)
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Evidence of cardiac tamponade
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Score ≥ 6 Score ≤ 6
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Pericardiocentesis
Guided by echocardiography or fluoroscopy
Bedside, ICU, Cardiac cath.labor operating room
Intercostal artery should beavoided
Subxiphoid approach ( longneedle directed towards the left
shoulder at a 30°
angle to theskin(ESC Guidelines on the Diagnosis &
Management of Pericardial Diseases-
2004
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Pericardiocentesis….
Stop the needle as soon as the effusion isaspirated
Exchange for soft J-tip guidewire and after dilatation for multi-holed pigtail catheter
Drain fluid in < 1 L steps to avoid the acute RVdilatation
Perform prolonge pericardial drainage until < 25 ml/day
(ESC Guidelines on the Diagnosis & Management of Pericardial Diseases- 2004)
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Surgical drainage
Indications for urgent surgical treatment of cardiactamponade include:
hemopericardium due to type A aortic dissection
ventricular free wall rupture in acute myocardialinfarction
trauma, or purulent effusion in unstable septicpatients
loculated effusions that can not be managedpercutaneously.
(ESC Guidelines on the Diagnosis & Management of Pericardial Diseases 2004)
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Summary
Cardiac tamponade is a life-threatening emergency and animportant cause of obstructive shock.
Tamponade can occur as a complication of a number of medical
conditions, as well as in trauma or cardiac surgery patients.
Prompt echocardiographic confirmation of tamponade should be
performed when the diagnosis is suspected.
Echocardiographic signs of right-sided diastolic chamber collapse
and ventricular interdependence are highly suggestive of cardiac
tamponade.
Treatment involves careful fluid resuscitation and inotropes,butthis is not a substitute for definitive drainage via either
percutaneous or open surgical techniques.
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Physical Examination Findings
Hypotension with pulsus paradoxus ( decreased systolicblood pressure > 10 mmHg during inspiration whereasdiastolic blood pressure remains unchange )
Muffled heart sounds : suppressed heart sounds occur due to the muffling effects of the fluid surrounding the
heart
Elevated JVP
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Physical Examination Findings
Tachycardia
Pericardial friction rub: can be found in patient cardiactamponade due to pericarditis , characterized by scratchy andgrating sound tends to be louder during inspiration with thepatient leaning forward. Best heard in left lower sternal border
Tachipneu