Pericardial effusion and tamponade: Difference between revisions

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==Background==
==Background==
*Always consider in pt w/ PEA
*Always consider in patient with PEA
*Always consider in pt w/ myocardial stab wound (80% result in tamponade)
*Always consider in patient with penetrating trauma anywhere in the cardiac box (80% result in tamponade)
**GSW is less likely to result in tamponade b/c 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 CO
**Increased pericardial pressure > decreased RV filling > decreased cardiac output


===Etiology===
===Etiology===
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**Ventricular rupture (post-MI)
**Ventricular rupture (post-MI)
*Non-hemopericardium
*Non-hemopericardium
**Cancer - most commonly lung, breast
**Cancer - most commonly lung, breast, prostate, or hematologic
***[[Melanoma]] has predilection for heart
***[[Melanoma]] has predilection for heart
***May be related to radiation, infection, chemotherapy
***May be related to radiation, infection, chemotherapy
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***Uremic ([[renal failure]])
***Uremic ([[renal failure]])
**[[HIV]] complications (infection, [[Kaposi sarcoma]], lymphoma)
**[[HIV]] complications (infection, [[Kaposi sarcoma]], lymphoma)
**[[SLE]]
**[[SLE]] and other autoimmune or connective tissue disorders
**Post-radiation
**Post-radiation
**[[Myxedema]]
**[[Myxedema]]
==Differential Diagnosis==
{{Template:Chest Pain DDX}}


==Clinical Features==
==Clinical Features==
*CP, SOB, fatigue
*[[Chest pain]], shortness of breath, cough, fatigue
*CHF-type appearance
*[[CHF]]-type appearance
*Narrow pulse pressure
*Narrow pulse pressure
*Friction rub
*Friction rub
*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


==Diagnosis==
==Differential Diagnosis==
#[[Ultrasound: Cardiac|Ultrasound]]
{{Template:Chest Pain DDX}}
#*Pericardial effusion
 
#**In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
==Evaluation==
#*Diastolic collapse of the right atrium (in atrial diastole)
===[[Pulsus Paradoxus]]===
#*Diastolic collapse of the right ventricle
*>10mmHg change in systolic BP on inspiration
#*Plethoric IVC
 
#*Valvular pulsus parodoxus
===[[CXR]]===
#**Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow
[[File:Massivepericarialeffusion.png|thumb|Massive pericardial effusion on chest x-ray]]
[[File:Pericardial Effusion.png|300px]]
*Enlarged cardiac silhouette
#[[ECG]]
 
#*Can be normal
===[[ECG]]===
#*Tachycardia (bradycardia is ominous finding)
[[File:Pericardial effusion with tamponade.png|thumb|Sinus tachycardia with low QRS voltage and electrical alternans]]
#*Electrical alternans
*Often normal
#*Low voltage
*Tachycardia (bradycardia is ominous finding)
#**All limb lead QRS amplitudes <5 mm;<ref>Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.</ref>
*Electrical alternans
#**OR All precordial QRS amp <10 mm
*Low voltage
#[[CXR]]
**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>
#*Enlarged cardiac silhouette
**'''OR''' All precordial QRS amplitudes <10 mm or V1+V2+V3<30
#[[Pulsus Paradoxus]]
 
#*>10mmHg change in systolic BP on inspiration
===[[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
**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]])
*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


==Treatment==
==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 ([[nitrates]], [[diuretics]])
**Avoid preload reducing medications ([[nitroglycerin]], [[diuretics]])


===Non-hemorrhagic Tamponade===
===Non-hemorrhagic Tamponade===
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==Disposition==
==Disposition==
*To OR if traumatic and hemodynamically unstable
*Admit with cardiology/CT surgery consult
*Admit with cardiology/CT surgery consult


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*[[Thoracic Trauma]]
*[[Thoracic Trauma]]
*[[Pericarditis]]
*[[Pericarditis]]
*[[Ultrasound: Cardiac]]
*[[Cardiac ultrasound]]


==Source==
==References==
<references/>
<references/>


[[Category:Cardiology]]
[[Category:Cardiology]]

Revision as of 05:52, 2 April 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

  • Hemopericardium
    • Trauma
    • Iatrogenic (misplaced central line)
    • Bleeding diathesis
    • Ventricular rupture (post-MI)
  • Non-hemopericardium
    • Cancer - most commonly lung, breast, prostate, or hematologic
      • Melanoma has predilection for heart
      • May be related to radiation, infection, chemotherapy
    • Pericarditis
    • HIV complications (infection, Kaposi sarcoma, lymphoma)
    • SLE and other autoimmune or connective tissue disorders
    • Post-radiation
    • Myxedema

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

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 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[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.