cardiac tamponade

Question 1

etiology of cardiac tamponade?

Answer 1

Hemopericardium :

Cardiac wall rupture (e.g., complication of myocardial infarction)

Chest trauma (traumatic cardiac tamponade)

Aortic dissection

Cardiac surgery (e.g., heart valve surgery, coronary bypass surgery or pacemaker implantation 0 - MOST COMMON

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Serous or serosanguinous pericardial effusion :

Idiopathic

Acute pericarditis (especially viral, but also fungal, tuberculous or bacterial)

Malignancy

Postpericardiotomy syndrome

Uremia

Autoimmune disorders

Question 2

what are the clinical manifestations of pericardial effusion ?

Answer 2

asymptomatic in most cases

SOB , especially when lying down

retrosternal chest pain

compressive symptoms - such as horsiness - recurrent laryngeal

nausea - compression of diaphragm

dysphagia - compression of oesophagus

hiccups - compression of hiccups

Ewart sign: dullness to percussion at the base of the left lung with increased vocal fremitus and bronchial breathing due the compression of lung parenchyma by the pericardial effusion

Question 3

what are the clinical manifestation of cardiac tamponade ?

Answer 3

BECK TRIAD
jugular vein distension
hypotension
muffled heart sounds

pluses parodoxus

A physical examination finding in which there is a pathologic decrease (> 10 mm Hg) in systolic blood pressure during inspiration. Classically associated with cardiac tamponade and constrictive pericarditis

tachycardia

pallor

Question 4

diagnosis of cardiac tamponade ?

Answer 4

Do not delay treatment for extensive diagnostic workup; proceed directly with management of cardiac tamponade.

TTE GOLDEN STANDARD or FATE - focused assessed tranthracic echocardiography

ECG
All patients with suspected pericardial effusion
Used to rule out an ischemic cause

findings in pericardial effusion - low voltage complex
electrical alternans in large effusion

findings in cardiac tamponade 
sinus tachycardia 
low voltage qrs 
elterical alternans - due to the shining motion go the heart the the qrs amplitude alternates 
PEA - pulseless eletrical activity 

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investigation of the underlying etiology
pericardiocentesis with pericardial fluid analysis

if glucose is less than 60-80mg/dl suggestive of malignant , parapneumonic or tuberculosis effusions

protein :
more than 6g/dl
associated with purulent , parapneumonic and tuberculous effusions

LDH
ISOLATED PERICARDIAL EFFUSION WITH ELEVATION OF 300 ants /dl suggests malignant effusion

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light criteria can be used for interpretation

TRANSUDATIVE
pleural fluid protein/serum protein ratio 0.5 and less

pleural fluid LDH/ serum lDH ratio
less than 0.6

pleural fluid LDH
less than 2/3 of the upper limit of normal of serum LDH

EXUDATIVE
>0.5
>0.6 (> 1 in the case of malignant pleural effusion.!!!!! )
pleural fluid LDH is more than 2/3 o the upper limit of normal serum LDH

very high pleural LDH suggests empyema , malignancy or rheumatoid effusion

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lab diagnosis

troponin- can be slightly elevated in pericarditis

Question 5

what are the different pericardial fluid types and thier according etiology ?

Answer 5

transudate
it is clear - caused by heart failure
renal failure
hypoalbuminea - liver damage

exudate 
it is cloudy and chylous 
due to viral infection 
inflammation 
malignancy 
AI

blood 
post cardiac surgery 
cardiac rupture 
aortic dissection 
tuberculosis 

purulent
thick and yellow appearance
tuberculosis

Question 6

what is the acute management of cardiac tamponade ?

Answer 6

call for cardiology immediately

A-E
establish two large bore IV access

cautious fluid resuscitation

inotropic support - such as dobutamine

confirm diagnosis - USUALLY A CLINICAL
POCUS with echocardiography if the patient is stable
if notpericardiocentesis

SUSPECT TAMPONADE IF MOE THAN ONE OF THE FOLLOWING
SOB
HR high 
JVP increse
pluses parodoxicus 
CXR - cardiac enlargement 

continuous telemetry - pulsoximeter, ECG , blood pressure

AVOID ANESTHETIC AGENTS AND POSTIVE PRESSURE VENTILATION -

help determine when urgent pericardiocentesis

Question 7

what is the management of pericardiocentesis in cardiac arrest due to cardiac tamponade

Answer 7

pause CPR to perform immediate periicardiocentesis
blind pericardiocentesis can be performed using landmarks if no US guidance

traumatic cardiac arrest
perform emergency throcatomy with vertical pericardiotomy