Pericardial effusion and tamponade: Difference between revisions
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==Background== | ==Background== | ||
*Always consider in | *Always consider in patient with PEA | ||
*Always consider in | *Always consider in patient with myocardial stab wound (80% result in tamponade) | ||
**GSW is less likely to result in tamponade b/c pericardial defect is larger | **GSW is less likely to result in tamponade b/c pericardial defect is larger | ||
*Pathophysiology | *Pathophysiology | ||
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===Etiology=== | ===Etiology=== | ||
*Hemopericardium | |||
**Trauma | |||
**Iatrogenic (misplaced [[central line]]) | |||
**Bleeding diathesis | |||
**Ventricular rupture (post-MI) | |||
*Non-hemopericardium | |||
**Cancer - most commonly lung, breast | |||
***[[Melanoma]] has predilection for heart | |||
***May be related to radiation, infection, chemotherapy | |||
**[[Pericarditis]] | |||
***Infectious | |||
***Uremic ([[renal failure]]) | |||
**[[HIV]] complications (infection, [[Kaposi sarcoma]], lymphoma) | |||
**[[SLE]] | |||
**Post-radiation | |||
**[[Myxedema]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 26: | Line 28: | ||
==Clinical Features== | ==Clinical Features== | ||
* | *[[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 | *Pulsus paradoxus (dec in BP on inspiration) | ||
*Beck's Triad (33% of patients) | |||
**Hypotension, muffled heart sounds, JVD | **Hypotension, muffled heart sounds, JVD | ||
== | ==Evaluation== | ||
===[[Cardiac ultrasound|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.<ref> | |||
Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982</ref> | |||
*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]]) | |||
[[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]] | |||
== | ===[[ECG]]=== | ||
*Can be 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== | |||
===Hemorrhagic Tamponade=== | ===Hemorrhagic Tamponade=== | ||
*Can occur if ECG read as STEMI/NSTEMI and heparin started | |||
*[[Pericardiocentesis]] | *[[Pericardiocentesis]] | ||
**Temporizing measure until [[thoracotomy]] can be performed | **Temporizing measure until [[thoracotomy]] can be performed | ||
*[[IVF]] to increase RV volume | *[[IVF]] to increase RV volume and maintain preload | ||
*Medications | *Medications | ||
**[[Pressors]] (temporizing) | **[[Pressors]] (temporizing) | ||
**Avoid preload reducing medications ([[ | **Avoid preload reducing medications ([[nitroglycerin]], [[diuretics]]) | ||
===Non-hemorrhagic Tamponade=== | ===Non-hemorrhagic Tamponade=== | ||
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==Disposition== | ==Disposition== | ||
*Admit with cardiology/CT surgery consult | |||
==See Also== | ==See Also== | ||
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*[[Thoracic Trauma]] | *[[Thoracic Trauma]] | ||
*[[Pericarditis]] | *[[Pericarditis]] | ||
*[[ | *[[Cardiac ultrasound]] | ||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Cardiology]] | ||
Revision as of 00:18, 20 August 2017
Background
- Always consider in patient with PEA
- Always consider in patient with myocardial stab wound (80% result in tamponade)
- GSW is less likely to result in tamponade b/c pericardial defect is larger
- Pathophysiology
- Increased pericardial pressure > decreased RV filling > decreased CO
Etiology
- Hemopericardium
- Trauma
- Iatrogenic (misplaced central line)
- Bleeding diathesis
- Ventricular rupture (post-MI)
- Non-hemopericardium
- Cancer - most commonly lung, breast
- Melanoma has predilection for heart
- May be related to radiation, infection, chemotherapy
- Pericarditis
- Infectious
- Uremic (renal failure)
- HIV complications (infection, Kaposi sarcoma, lymphoma)
- SLE
- Post-radiation
- Myxedema
- Cancer - most commonly lung, breast
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
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)
- 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
ECG
- Can be 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
- 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
- Admit with cardiology/CT surgery consult
See Also
References
- ↑ Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982
- ↑ 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.
- ↑ Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.