Pericardial effusion and tamponade: Difference between revisions

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==Pathophysiology==
==Pathophysiology==
 
#see pericarditis
 
#hemodynamic compromise from inc pericardial fluid
-see pericarditis
##incr pericardial pressures
 
##decr diastolic filling, venous return, collapse of RA
-hemodynamic compromise from inc pericardial fluid
##inhalation sequesters fluid in pulm vasc, not LV
 
    -incr pericardial pressures
 
    -decr diastolic filling, venous return, collapse of RA
 
    -inhalation sequesters fluid in pulm vasc, not LV
 


==Signs & Symptoms==
==Signs & Symptoms==
 
#Rapidity of fluid accumulation determines clinical effects
 
#Rapid accumulation: as little as 150cc may decr cardiac output
-Rapidity of fluid accumulation determines clinical effects
#Slow accumulation: as much as 2L may have little effect
 
#Pts may c/o CP, dyspnea, fatigue, anorexia, wt loss, MS changes, shock
-Rapid accumulation: as little as 150cc may decr cardiac output
#Overall: looks a lot like CHF with JVD, SOB, hepatomegaly, etc...
 
#Narrow pulse pressure
-Slow accumulation: as much as 2L may have little effect
#Friction rub
 
#Beck's Triad
-Pts may c/o CP, dyspnea, fatigue, anorexia, wt loss, MS changes, shock
##hypotension, muffled heart sounds, JVD
 
##present in only 30% of pts
-Overall: looks a lot like CHF with JVD, SOB, hepatomegaly, etc...
##90% will have at least one of the three findings
 
#Pulsus paradoxus
-Narrow pulse pressure
##>10mmHg change in sys BP on inspiration
 
##decreased intrathoracic P on inspiration causes increased return to R heart --> R septum bows into L given constriction by surrounding pericardial effusion --> decreased LVEDV and concomitant decreased CO
-Friction rub
##can see in many right heart dz states as well
 
##may NOT see in acute trauma
-Beck's Triad: hypotension, muffled heart sounds, JVD
#Ewart's sign (compressive atelectasis causes pulmonary auscultatory changes)
 
    -present in only 30% of pts
 
    -90% will have at least one of the three findings
 
-Pulsus paradoxus
 
    - >10mmHg change in sys BP on inspiration
 
          -decreased intrathoracic P on inspiration causes increased return to R heart --> R septum bows into L given constriction by           surrounding pericardial effusion --> decreased LVEDV and concomitant decreased CO
 
    -can see in many right heart dz states as well
 
    -may NOT see in acute trauma
 
-Ewart's sign (compressive atelectasis causes pulmonary auscultatory changes)
 


==Work-Up==
==Work-Up==
 
#Pulsus paradoxus (old school)
 
#EKG
-Pulsus paradoxus (old school)
##nl or diffuse low QRS
 
##electrical alternans (beat to beat QRS amp vary)
-EKG -nl or diffuse low QRS
#CXR: CM, obliteration of costophrenic angles
 
#TTE -modality of choice: effusion, diffuse hypokinesis, RA and RV collapse
    -electrical alternans (beat to beat QRS amp vary)
#labs: CBC, chem 10, coags, enzymes
 
#consider: HIV, ANA, ESR, RF, PPD
-CXR: CM, obliteration of costophrenic angles
#pericardial fluid for viral/bact Cx, cell count, cytology
 
-TTE -modality of choice: effusion, diffuse hypokinesis, RA and RV collapse
 
-labs: CBC, chem 10, coags, enzymes
 
-consider: HIV, ANA, ESR, RF, PPD
 
-pericardial fluid for viral/bact Cx, cell count, cytology
 


==Causes==
==Causes==
As in pericarditis
As in pericarditis
 
#idiopathic
- idiopathic
#infectious, including AIDS related, TB
 
#malignancy: heme, lung, breast
- infectious, including AIDS related, TB
#uremia
 
#post radiation
- malignancy: heme, lung, breast
#connective tissue dz
 
#drugs: procainamide, hydralaine, methyldopa, anticoagulants
- uremia
#cardiac injury (can see up to weeks later): post MI, trauma, aortic  dissection
 
- post radiation
 
- connective tissue dz
 
- drugs: procainamide, hydralaine, methyldopa, anticoagulants
 
- cardiac injury (can see up to weeks later): post MI, trauma, aortic  dissection
 


==DDx==
==DDx==
 
#Tension PTX
 
#PE
Tension PTX
#SVC syndrome
 
#large pleural effusion
PE
#Tension pneumocardium
 
#Constrictive pericarditis
SVC syndrome
#Cardiogenic shock
 
large pleural effusion
 
Tension pneumocardium
 
Constrictive pericarditis
 
Cardiogenic shock
 


==Treatment==
==Treatment==
EMERGENCY
EMERGENCY
 
#ABCs, IV, O2, monitor
-ABCs, IV, O2, monitor
#IV fluids to incr RV vol
 
#Pressors (temporizing)
-IV fluids to incr RV vol
#AVOID preload reducing meds eg Nitrates, diuretics
 
#Procedures: see Pericardiocentesis
-Pressors (temporizing)
#Pericardial window (OR)
 
-AVOID preload reducing meds eg Nitrates, diuretics
 
-Procedures: see Pericardiocentesis
 
-Pericardial window (OR)
 


==Disposition==
==Disposition==
 
#likely ICU
 
#Cards, CT surg consults
-likely ICU
 
-Cards, CT surg consults
 


==Source==
==Source==
Cards: Pericarditis
Cards: Pericarditis


==Source==
==Source==
Adapted from Donaldson
Adapted from Donaldson


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

Revision as of 17:35, 12 March 2011

Pathophysiology

  1. see pericarditis
  2. hemodynamic compromise from inc pericardial fluid
    1. incr pericardial pressures
    2. decr diastolic filling, venous return, collapse of RA
    3. inhalation sequesters fluid in pulm vasc, not LV

Signs & Symptoms

  1. Rapidity of fluid accumulation determines clinical effects
  2. Rapid accumulation: as little as 150cc may decr cardiac output
  3. Slow accumulation: as much as 2L may have little effect
  4. Pts may c/o CP, dyspnea, fatigue, anorexia, wt loss, MS changes, shock
  5. Overall: looks a lot like CHF with JVD, SOB, hepatomegaly, etc...
  6. Narrow pulse pressure
  7. Friction rub
  8. Beck's Triad
    1. hypotension, muffled heart sounds, JVD
    2. present in only 30% of pts
    3. 90% will have at least one of the three findings
  9. Pulsus paradoxus
    1. >10mmHg change in sys BP on inspiration
    2. decreased intrathoracic P on inspiration causes increased return to R heart --> R septum bows into L given constriction by surrounding pericardial effusion --> decreased LVEDV and concomitant decreased CO
    3. can see in many right heart dz states as well
    4. may NOT see in acute trauma
  10. Ewart's sign (compressive atelectasis causes pulmonary auscultatory changes)

Work-Up

  1. Pulsus paradoxus (old school)
  2. EKG
    1. nl or diffuse low QRS
    2. electrical alternans (beat to beat QRS amp vary)
  3. CXR: CM, obliteration of costophrenic angles
  4. TTE -modality of choice: effusion, diffuse hypokinesis, RA and RV collapse
  5. labs: CBC, chem 10, coags, enzymes
  6. consider: HIV, ANA, ESR, RF, PPD
  7. pericardial fluid for viral/bact Cx, cell count, cytology

Causes

As in pericarditis

  1. idiopathic
  2. infectious, including AIDS related, TB
  3. malignancy: heme, lung, breast
  4. uremia
  5. post radiation
  6. connective tissue dz
  7. drugs: procainamide, hydralaine, methyldopa, anticoagulants
  8. cardiac injury (can see up to weeks later): post MI, trauma, aortic dissection

DDx

  1. Tension PTX
  2. PE
  3. SVC syndrome
  4. large pleural effusion
  5. Tension pneumocardium
  6. Constrictive pericarditis
  7. Cardiogenic shock

Treatment

EMERGENCY

  1. ABCs, IV, O2, monitor
  2. IV fluids to incr RV vol
  3. Pressors (temporizing)
  4. AVOID preload reducing meds eg Nitrates, diuretics
  5. Procedures: see Pericardiocentesis
  6. Pericardial window (OR)

Disposition

  1. likely ICU
  2. Cards, CT surg consults

Source

Cards: Pericarditis

Source

Adapted from Donaldson

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