Pericardial Disease - Pericardial Effusion and Cardiac Tamponade

Question 1

What is Pericardial Effusion?

Answer 1

A state where excess fluid collects within the pericardial sac to fill the entire pericardial cavity or only a localised section.

Question 2

What can the effusion be made up of? (5)

Answer 2

1. Transudates.
2. Exudates.
3. Blood.
4. Pus.
5. Gas (Bacterial Infections).

Question 3

What is the Pericardium?

Answer 3

A membrane that surrounds the heart - 2 layers with a small amount of fluid to provide lubrication and separate the heart from the rest of the contents of the mediastinum.

Question 4

How is the Pleurae similar to the Pericardium?

Answer 4

Both are POTENTIAL SPACEs between the 2 layers.

Question 5

What is the difference between Pericardial Effusion and Pericardial/Cardiac Tamponade?

Answer 5

Pericardial Effusion : the potential space fills with fluid creating an inward pressure on the heart, making it more difficult to expand during diastole.

Cardiac Tamponade : large enough to raise the intra-pericardial pressure - an emergency since there is reduced CO.

Question 6

What may cause a transudative pericardial effusion?

Answer 6

Increased venous pressure results in reduced drainage - CCF, Pulmonary HTN.

Question 7

What may cause an exudative pericardial effusion? (6)

Answer 7

Inflammatory process - pericarditis e.g.
1. Infection (TB, HIV, Cox-Sackie, EBV).
2. Autoimmune : SLE, RA.
3. Injury : MI, Surgery, Trauma.
4. Uraemia : Renal Impairment.
5. Cancer.
6. Medications : Methotrexate.

Question 8

Aetiology of a Rapid-Onset Cardiac Tamponade (3).

Answer 8

Rupture of Heart/Aorta = Bleeding into the Pericardial Cavity :
1. MI.
2. Trauma.
3. Type A Aortic Dissection.

Question 9

Clinical Presentation of Chronic Pericardial Effusion (5).

Answer 9

1. Initially Asymptomatic.
2. Chest Pain.
3. SOB.
4. Feeling of Fullness in Chest.
5. Orthopnoea.

Question 10

How would a Cardiac Tamponade present?

Answer 10

Haemodynamic Compromise and Collapse.

Question 11

Give 3 extra-cardiac symptoms of a Pericardial Effusion.

Answer 11

1. Hiccups - Phrenic Nerve Compression.
2. Dysphagia - Oesophageal Compression.
3. Dysphonia - Recurrent Laryngeal Nerve Compression.

Question 12

Give 4 signs on examination of Pericardial Effusion.

Answer 12

1. Quiet Heart Sounds.
2. Pulsus Paradoxus.
3. Hypotension.
4. Raised JVP.

Question 13

What is Beck’s Triad?

Answer 13

CARDIAC TAMPONADE TRIAD :
1. Hypotension.
2. Raised JVP.
3. Muffled Heart Sounds.

Question 14

What is Pulsus Paradoxus?

Answer 14

An abnormally large drop in BP during inspiration, notably when palpating the pulse.

Question 15

What is the investigation of choice in Pericardial Effusion & what is its role?

Answer 15

Echocardiogram :
1. Diagnosis.
2. Assess Size.
3. Assess Haemodynamic Effect.

Question 16

What other investigation can be used, to diagnose the underlying cause? (3)

Answer 16

FLUID ANALYSIS :
1. Protein Content.
2. Bacterial Culture, Viral PCR.
3. Cytology, Tumour Markers.

Question 17

What is the ECG finding in Cardiac Tamponade?

Answer 17

Electrical Alternans (alternation of QRS complex amplitude between beats).

Question 18

How can Cardiac Tamponade be differentiated from Constrictive Pericarditis? (4)

Answer 18

CONSTRICTIVE PERICARDITIS :
1. JVP - X+Y Present (Absent Y Descent in Cardiac Tamponade).
2. No Pulsus Paradoxus.
3. Kussmaul’s Sign (Rare in Cardiac Tamponade).
4. CXR : Pericardial Calcification (n/a in Cardiac Tamponade).

Question 19

Aims of Management of Pericardial Effusion (2).

Answer 19

1. Treatment of Underlying Cause.
2. Drainage of Effusion.

Question 20

How can Inflammatory Causes of Pericardial Effusion be treated? (4)

Answer 20

1. Aspirin.
2. NSAIDs.
3. Colchicine.
4. Steroids.

Question 21

What are the 2 options for draining an effusion?

Answer 21

1. Needle Pericardiocentesis (ECHO-guided).
2. Surgical Drainage.

Question 22

What is a Pericardial Window?

Answer 22

Surgical procedure - removal of a portion of the pericardium to create a window/fistula to allow fluid to drain from the pericardial cavity into the pleural cavity or the peritoneal cavity.

Question 23

What management option may be used in recurrent cases?

Answer 23

Rarely, PERICARDIECTOMY.

Question 24

Management of Cardiac Tamponade.

Answer 24

Urgent Pericardiocentesis.

Question 25

What is a complication of Pericardiocentesis?

Answer 25

Pneumothorax : CXR Post-Procedure.