Pericardial effusion Flashcards
What is a pericardial effusion
Describes a collection of fluid in the pericardial space
Types of pericardial effusions
Transudate(hydropericardium)
Exudate(pyopericardium)
Haemopericardium
Common causes of large pericardial effusions
Neoplasms Tuberculosis Uraemic pericarditis Myxoedema Parasitic infections
When are loculated effusions more common
When scarring is present(eg, post-surgery, post-trauma, post-purulent pericarditis)
Causes of pericardial effusions
Idiopathic Infectious pericarditis MI AKI/CKD Malignancy Benign tumours Hypothyroidism Trauma
Drugs associated with pericardial effusions
Hydralazine Isoniazid Minoxidil Phenytoin Anticoagulants
Symptoms of pericardial effusion
Chest pain/discomfort Light-headedness/syncope Palpitations Cough/SOB/hoarseness Anxiety and confusion
Classic triad associated with pericardial tamponade
Hypotension
Muffled heart sounds
Jugular venous distention
Signs associated with pericardial effusion
Pulsus paradoxus
Percardial friction rub
Tachycardia
Resp signs(tachypnoea, decreased breath sounds and Ewart’s sign)
Hepatosplenomegaly, weakened peripheral pulses, oedema and cyanosis
How a pericardial effusion show on an ECG
May show raised ST segments with myocardial infarction or pericarditis
Diminished QRS and T-wave voltages, PR-segment depression, ST-T changes, bundle branch block and electrical alternans
What is a raised carcinoembryonic antigen level in the presence of a pericardial fluid level highly specific for
Malignant effusion
Cardiac tamponade vs pericardial effusion
Pericardial effusion is an anatomic diagnosis of abnormal pericardial fluid accumulation that has no haemodynamic consequences, whereas cardiac tamponade is a physiologic diagnosis of varying amounts of pericardial fluid that causes haemodynamic consequences
Pharmacological management of pericardial effusions
Oxygen therapy
Treatment of underlying condition(eg cytotoxic agents for malignancy, or steroids and NSAIDs for RA)
IV fluids if hypovolaemic
Surgical interventions for pericardial effusions
Pericardiocentesis
Pericardotomy if effusion recurs
Pericardial sclerosis
When is pericardiocentesis contra-indicated
Wounds
Ruptured ventricular aneurysm
Dissecting aortic haematoma
Examples of sclerosing agents for pericardial sclerosis
Tetracycline
Doxycycline
Cisplatin
Complications of pericardial sclerosis
Severe pain
Fever
Infection
Atrial dysrhythmias
Complications of pericardial effusions
Pericardial tamponade - can lead to severe haemodynamic compromise and death
Chronic pericardial effusion(effusions lasting longer than 6 months and they are usually well tolerated)
Signs of cardiac tamponade
Distended neck veins Hypotension Tachycardia/tachypnoea Muffled heart sounds Pericardial friction rub Hepatomegaly Pulsus paradoxus
What is beck’s triad
Acute tamponade leads to increased jugular venous pressure(JVP) - jugular venous distension, hypotension and diminished heart sounds(rarely seen)
What is a good way of distinguishing patients with cardiac tamponade in patients with known pericardial effusion
Exaggeration of the normal decrease in systemic blood pressure during inspiration; a pulsus paradoxus greater than 10 mm Hg
This sign is more reliable in patients with high-pressure rather than low-pressure tamponade
Ix of choice for cardiac tamponade/pericardial effusion
Transthoracic echocardiogram
Management of cardiac tamponade
Oxygen Volume expansion(small boluses) Improve venous return(bed rest with leg elevation) Positive inotropic drugs Treat underlying cause
Example of positive inotropic drug used in cardiac tamponade management
Dobutamine
Why should positive pressure mechanical ventilation be avoided in cardiac tamponade management
May decrease venous return
surgical management of cardiac tamponade
Pericardiodesis
Corticosteroids, tetracycline or antineoplastic drugs
Pericardio-peritoneal shunt to prevent recurrent tamponade in malignant pericardial effusions
Pericariectomy
Symptoms of pericarditis
Sharp pleuritic chest pain
Relief of pain with sitting up or leaning forward
Generally constant
What is a pericardial rub
Superficial scratchy or squeaking sound best heard with the diaphragm over the left sternal border with the patient leaning forward at end-expiration
Indicative of pericarditis
How can a pericardial friction rub be distinguished from a pleural rub
Ask patient to hold their breath - a pericardial friction rub will still be heard when patient holds breath
Causes of acute pericarditis
Idiopathic Underlying systemic condition(SLE, RA) Viral infections(Coxsackievirus, EBV, CMV) Radiotherapy Cardiac surgery
ECG changes in pericarditis
Global upwardly concave ST-segment(J-point) elevations with PR-segment depressions in most leads
Use of serum troponin in diagnosis of pericarditis
Elevated levels may reflect pericarditis with myocardial involvement but not specific or sensitive
Management of suspected pericarditis
Triage and consider admission to hospital
Consider pericardiocentesis in suspected tamponade
High risk features indicative of a need for inpatient management in pericarditis
High fever(>38 degrees) Subacute course Evidence of large pericardial effusion Cardiac tamponade Failure to respond within 7 days to NSAID
Management of idiopathic or viral(non-purulent) pericarditis
NSAID PPI Colchicine Exercise restriction Corticosteroid
Management of purulent pericarditis
IV antibiotic therapy(anti-staphylococcal antibiotic plus an aminoglycoside)
Specialist referral
