CARDIO: MISC incl Cardiac tamponade, pericarditis, toxicity Flashcards
What is Cardiac Tamponade? Mechanism of how it happens?
Accumulation of fluid, blood, purulent exudate or air in the pericardial space.
This raises intra pericardial pressure.
Diastolic filling is reduced, which reduces cardiac output.
Life threatening emergency that requires prompt diagnosis with echocardiogram and treatment.
How would a pt with cardiac tamponade present?
Shortness of breath Tachycardia Confusion Chest pain Abdominal pain
What are the signs of cardiac tamponade. Hint a helpful ____ triad?
BECK’S Triad of signs:
- Hypotension
- Quiet heart sounds
- Raised JVP
Other signs:
dyspnoea
pulsus paradoxus - an abnormally large drop in BP during inspiration.
an absent Y descent on the JVP - this is due to the limited right ventricular filling
What are RF for cardiac tamponade?
malignancy,
purulent pericarditis,
severe thoracic trauma.
What investigations for Cardiac tamponade?
ECG - low voltage QRS complexes or electrical alternans (alternating QRS amplitude)
Chest x-ray - show a large globular heart
ECHO - fluid around the heart and quantify the level of ventricular compromise.
Pericardiocentesis - sampling of the fluid to find the underlying cause and treat the immediate problem.
What is first line management for cardiac tamponade in a haemodynamically unstable pt?
pericardiocentesis
using a needle and small catheter to drain excess fluid
In a pt with cardiac tamponade when would surgical drainage be indicated as first line management ?
In patients with haemopericardium, associated malignancy, traumatic/purulent effusion
What are some complications of pericardiocentesis?
pneumothorax (all patients should have a CXR post procedure to exclude this)
Damage to the myocardium / coronary vessels
Thrombus
Arrhythmias/cardiac arrest
Damage to the peritoneum.
Causes of non-cardiac chest pain?
Costo-chondritis Gastro-oesophageal PE Pneumonia Pneumothorax Psychogenic/psychosomatic
What is top differencial for Cardiac tamponade?
Constrictive pericarditis
How would differentiate between cardiac tamponade and constrictive pericarditis?
CT
- absent Y descent JVP - reduced RV filling
- Pulsus paradoxus - (+ drop in BP w/inspiration)
CP
- Y+ X present in JVP
- no Pulsus paradoxus
- Kussmaul’s sign +ve
- Pericardial calcification seen on CXR
How does GTN spray help alleviate symptoms of angina
CVS revision
1) Nitric oxide causes vascular smooth muscle relaxation. NO activates granulate cyclase which increases cGMP. this lowers intracellular calcium levels so causes relaxation of vascular smooth muscle.
2) It acts primarily on veins - ventilation will lower preload. So the heart will fill less so force of contraction is reduced. This lowers oxygen demand needed.
3) GTN also acts on coronary collateral arteries - so improves oxygen delivery to the ischaemic heart muscle.
ECG findings in PE?
Sinus tachycardia
“S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign.
—> A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain
Symptoms of digoxin toxicity?
- abdo pain
- nausea
- vomitting
- arrythmia
- yellow-green tint to vision
- diarrhoea
- confusion
- fatigue
- palpitations
RF for digoxin toxicity?
- hypokalaemia
- hypomagnesia
- hypercalcaemia
- elderly
ECG changes in digoxin toxicity?
- Downsloping ST depression - ‘Reverse Tick’
- T wave changes (inversion)
- Biphasic/flattened and shortened QT interval
- Slight PR interval prolongation
Treatment for digoxin toxicity?
Stop digoxin
Correct dyselectrolytaemia
Administer digifab (digoxin specific antibody indicated in lifethreatening digoxin toxicity).
What is dresslers syndrome?
central, pleuritic chest pain and fever 4 weeks following a myocardial infarction. The ESR is elevated - Dressler’s syndrome
What is acute pericarditis?
inflammation of the pericardial sac, lasting for less than 4-6 weeks.
Causes of acute pericarditis?
- viral infections (Coxsackie)
- tuberculosis
- uraemia
- post-myocardial infarction
- early (1-3 days): fibrinous pericarditis
- late (weeks to months): autoimmune pericarditis (Dressler’s syndrome)
- radiotherapy
- connective tissue disease
- systemic lupus erythematosus
- rheumatoid arthritis
- hypothyroidism
- malignancy
lung cancer
breast cancer - trauma
Features of pericarditis?
- chest pain: may be pleuritic. Is often relieved by sitting forwards
- other symptoms include a non-productive cough, dyspnoea and flu-like symptoms
- pericardial rub: heard as a scratching or creaking noise at the left lower sternal border.
Inv for acute pericarditis?
Bedside:
* ECG: widespread saddle shaped ST elevation, PR depression
Bloods:
* FBC- for WBCs
* CRP
* Troponins (may be elevated, this could be myocrditis)
Imaging:
* Transthoracic echocardiography
Management of acute pericarditis?
- the majority of patients can be managed as outpatients
patients who have high-risk features such as fever > 38°C or elevated troponin should be managed as an inpatient - treat any underlying cause
most patients however will have pericarditis secondary to viral infection, meaning no specific treatment is indicated - strenuous physical activity should be avoided until symptom resolution and normalisation of inflammatory markers
- a combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis
- until symptom resolution and normalisation of inflammatory markers (usually 1-2 weeks) followed by tapering of dose recommended over
