Pericardial Effusion & Tamponade Flashcards
1
Q
Pericardial Effusion
definition
A
presence of an abnormal amount/or type of fluid between the parietal and visceral layers of pericardium
2
Q
Pericardial Effusion
What are the layers of heart wall?
A
3
Q
PE Size & Etiology
Trivial pericardial effusion is only visible during ______
A
systole
4
Q
PE Size & Etiology
Small PE is ______ mm ( _____ mL) by echo
&
the causes are:
A
< 10mm, 50-100 mL
acute pericaditis
idiopathic
infectious (usually viral)
5
Q
PE Size & Etiology
Moderate PE is ______ cm ( _____ mL) by echo
&
the causes are:
A
1-2 cm
100-500 mL
various causes
6
Q
PE Size & Etiology
Large PE is ______ mm / very large is ____ mm (____ mL) by echo
&
the causes are:
A
- >20 mm
- >25 mm, >500 mL
- hypothyroidism
- neoplasia (abnormal growth/atypical proliferation of tissue)
- tubeculosis
7
Q
PE Size & Etiology
Rapid accumulation
the causes are:
A
- acute MI with cardiac rupture
- Asc aortic dissection
- blunt trauma
- cardiac ;perforation (cath procedure or other)
8
Q
PE other causes
A
- auto immune/inflammatory/connective tissue disorders
- benign/malignant tumor or metastatic cancer to pericardium
- drug induced
- infectious (viral/bacterial/fungal/HIV/AIDS/tubeculosis)
- kidney failure (excessive nitrogen blood levels)
- post MI (*Dressler’s syndrome) or surgery
- radiation/chemotherapy
9
Q
PE Signs & Symptoms
small PE is usually ______ and found accidentally on chest x-ray or echo
A
asymptomatic
10
Q
PE Signs & Symptoms
Symptoms are often due to:
A
compression of the heart, stomach, lungs, or peripheral nerve
11
Q
PE Signs & Symptoms
A
- CP/pressure/discomfort
- palpitation
- cough
- hoarseness
- SOB
- dysphagia
- nausea
- feeling of abdominal fullness
- light headed
- anxiety
- confusion
- syncope
12
Q
PE Differential Diagnosis
PE is sometimes confused with _____ or _______
A
pleural effusion
epicardial fat
13
Q
PE Differential Diagnosis
_______ is the ideal view to differentiate a pericardial effusion from a pleural effusion.
A
PLAX
14
Q
PE Differential Diagnosis
A pleural effusion is positioned ________, appears very large, and may change with _____.
A
posterior to DAO
respiration
15
Q
PE Differential Diagnosis
If both pleural effusion and pericardial effusion are present, visualize _______ between them
A
pericardium
16
Q
PE Differential Diagnosis
______ is a measure of visceral fat and has been linked to increased risk for CAD, metabolic syndrome, and insulin resistance.
A
epicardial fat
17
Q
PE Differential Diagnosis
By echo, epicardial fat is best visualized on the ______, usually in _____ or ____ views.
A
RVFW
PLAX
Sub
18
Q
PE Differential Diagnosis
epicardial fat is seen as an echo free space between the ________ and ________
A
the outer wall of myocardium
the visceral layer of the pericardium
19
Q
PE Differential Diagnosis
Epicardial fat appears _____ than the myocardium and moves _______.
A
brighter/gelatinous
with the heart
20
Q
PE Differential Diagnosis
epicardial fat measurements have been acquired from _______ mm
A
1-23
21
Q
PE
PE frequently originates near _____ because it has the ______ pressure of the four chambers; therefore the other chambers tend to squeeze the effusion to the area of the least resistance.
A
RA
lowest
22
Q
PE
It is unusual for a PE to be positioned solely ______ to the heart, unless it is loculated. A loculated effusion is more common _________ or ________
A
anterior
post cardiac surgery
metastatic disease
*note: loculated: the compartmentalization of a fluid-filled cavity into smaller spaces (locules) by fibrous septa
23
Q
PE
________ may contain fibrin strands, adhesions, or uneven distribution.
A
exudative pericardial effusion
Exudative effusions are caused by an inflammatory or malignant process affecting the pleura, causing increased capillary permeability and fluid accumulation. Common causes of exu-dates include pneumonia, cancer, tuberculosis and pulmonary embolism
24
Q
PE
Fibrin strands are frequently present with a long standing PE or one associated with metastatic disease.
T or F ?
A
T
25
_Tamponade_
definition
a potentially life-threatening PE with significant hemodynamic compromise on cardiac filling and function
26
_Tamponade_
signs/symptoms
* excessive pericardial fluid accumulates - the effusion compresses the heart and limits cardiac filling
* **dyspnea** \*improves when the patient sit up
* **SOB**
* altered mental status/**anxiety**
* **cold extremities/peripheral cyanosis**
* **blue lips/skin**
* **dysphagia**
* **cough**
* **fatigue/weakness**
* **hypotension**
* **lightheaded/dizziness/syncope**
* **tachycardia**
* **cardiogenic shock**
* **impaired diastolic filling** (progressively worsens)
* elevation and equalization of diastolic and pericardial pressures
* **reduced CO**
* insufficient preload - unable to sustain cardiac filling - result in a dramatic decrease in coronary and systemic perfusion
* **cardiac arrest/death**
27
_Tamponade_
can be acute, subacute, or chronic; mild to severe, and potentially life-threatening. Low-pressure tamponade is possible due to hypovolemia or over-diuresis.
T or F ?
T
28
_Tamponade_
Regional tamponade affects selected chambers, usually _______ heart due to a loculated effusion or precordial blood clot post cardiac surgery or MI
left
29
_Tamponade_
It is important to remember that tamponade is a clinical diagnosis; echo determines:
* size, location of the PE
* presence and degree of hemodynamic comprise on the cardiac filling and function
30
_Tamponade_
Clinical Presentation
* Beck's Triad
* Pulsus paradoxus: an exaggerated decrease in systolic BP with inspiration
* pericardial friction rub
* tachycardia
* dyspnea \*may improve when the patient is upright
* hepatomegaly \*enlarged liver due to increased venous pressure
31
_Tamponade_
What is Beck's Triad?
* hypotension and weak pulse due to low CO
* muffled heart sound due to fluid around the heart
* elevated venous pressure and extended neck veins because it is difficult to return blood to the heart
32
_Tamponade_
causes
* asc aortic dissection
* autoimmune/connective tissue/inflammatory disease
* cardiac surgery
* cardiac perforation (cath procedure or other)
* CM
* hypothyroidism
* infectious (viral, bacterial, fungal, HIV/AIDS, tuberculosis)
* kidney failure/uremia (urea in blood)
* large PLE
* malignant disease
* MI
* pericarditis
* radiation therapy/chemotherapy
33
_Tamponade_
Treatment
* **O2, fluids, medical therapy**
* **pericardiocentesis** (aka: pericardial trap): the physician/surgeon taps (drains) the pericardial effusion via aspiration \*_quick_ **_bubble study_** _can verify catheter location & fluid sample sent to the lab for culture_
* **pericardial window**: open pericardial drainage via a window made by the surgeon
* **pericardiectomy**: removal of pericardium by the surgeon
34
_Tamponade_
2D Echo presentation
* **swinging** heart is possible for a large PE
* **decreased LV diastolic/systolic dimensions**
* wall may appear **hypertrophied**
* ventricular respiratory variation
* **LV** diastolic dimension - **_decreases_** _with inspiration_
* **RV** diastolic dimension - **i_ncreases_** _with inspiration_
* **IVS inspiratory bounce**
* **RA late diastolic collapse**
* **RV diastolic collapse**
* _early on_, RV diastolic collapse is present **during inspiration**
* as the _tamponade severity increases_, the collapse remains **throughout the respiratory cycle**. ***the longer the collapse = the more severe the tamponade*** **\*tip:** compare RV wall motion to the MV/TV motion - _diastolic collapse occurs while these valves are open_
* **paradoxical septal motion** - the walls move _parallel to one another_ than their normal contraction (toward) and relaxation (away).
* **dilated hepatic veins/IVC** with a lack of respiratory collapse - reflects elevated systemic venous pressure
35
36
* Pericarditis/ Pericardial Effusion is an infiltration of inflammatory cells into the pericardium*
* List 4 causes:*
* **acute injury**
* **post MI**
* **autoimmune/c**ollagen vascular disease
* **cancer**
* HIV/AIDS
* **infections**
* kidney failure
* **radiation therapy**
* **tuberculosis**
* congenital anomaly
* **idiopathic**
37
*List 4 complications of infective endocarditis.*
* cusps/leaflet rupture frail
* perforation
* abscess
* aneurysm
* fistula
* Dehiscence of prosthetic valve
* PE
38
*List 4 signs/symptoms of the clinical presentation of pericarditis.*
* CP
* dyspnea
* fever
* palpitation
* odynophagia (painful swalloing)
* elevated cardiac enzyme
39
*This structure may mimic infective endocarditis. What is it?*
**Lambl’s excrescences**
## Footnote
Lambl's excrescences (LE) are **filiform fronds that occur at sites of valvular closure**. They may be found without any other evidence of cardiac disease. 1,2. They originate as small thrombi on endocardial surfaces where the valve margins make contact. These are the sites of minor endothelial damage, due to wear and tear
40
*List 3 common locations for endocarditis in the heart*
* atrial side of MV & TV
* ventricular side of AoV & PV
* secondary jet lesions
41
*List 3 less common locations for endocarditis in the heart*
* chordae
* Eustachian valve
* pacemaker wire
42
***The following are considered ______________________ on the Duke list.***
## Footnote
* 1.Predisposition, predisposing heart condition, or injection drug use*
* 2.Fever, temperature \> 38ºC*
* 3.Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions*
* 4.Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor*
* 5.Microbiological evidence: positive blood culture, but does not meet a major criterion as noted previously; or serologic evidence of active infection with organism consistent with IE*
Minor criteria
43
***The following are considered ______________________ on the Duke list.***
major criteria
44
*The marks on the finger nail of this patient could indicate infective endocarditis. What are they called?*
splinter hemorrhages
**reddish, thin lines appearing under nails**
45
* TEE is superior to 2D echo for detection of vegetations or ring abscess.*
* T or F ?*
T
## Footnote
**TEE is superior to 2D echo for detection of vegetations or ring abscess**
46
*The parietal pericardium is fused to the __________________ pericardium.*
fibrous
47
*Patients with infective endocarditis may present with these symptoms. These are \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.*
* Fever – usually low grade
* Fatigue / weakness
* “Flu-like” symptoms
* Weight loss
48
_Infective Endocarditis Etiology_
## Footnote
*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ , usually seen as a right sided infection in IV drug users is a (skin flora)*
**Staphylococcus aureus**
49
_Infective Endocarditis Etiology_
* streptococcus (mouth flora) \*most common
* staphylococcus (skin flora)
50
*The pericardium is divided into two layers, the fibrous (outer) and serous (inner) which is divided into two layers, the ___________ and ___________ layers.*
parietal
visceral
51
*The pericardial space lies between the \_\_\_\_\_\_\_\_1\_\_\_\_\_\_\_\_\_\_\_\_\_ and \_\_\_\_\_\_\_\_\_\_2\_\_\_\_\_\_\_\_ pericardium.*
1. parietal
2. visceral
52
The epicardium is immediately outside of the myocardium and is a part of the \_\_\_\_\_\_\_\_
visceral pericardium
53
*List 4 **physical findings** of infective endocarditis.*
* Petechiae
* splinter hemorrhages
* Osler's nodes
* Janeway's lesions
54
what is this?
**Petechiae** are tiny purple, red, or brown spots on the skin. They usually appear on your arms, legs, stomach, and buttocks. You might also find them inside your mouth or on your eyelids. These pinpoint spots can be a sign of many different conditions — some minor, others serious. They can also appear as a reaction to certain medications.
55
What is this?
Osler's node
## Footnote
**ed, tender, raised, tender lesions located in pulp of fingers and toes**
56
What is this?
**Janeway’s lesions**
## Footnote
**rregular, nontender hemorrhagic macules located on the palms, soles, thenar and hypothenar eminences of the hands, and plantar surfaces of the toes**. They typically last for days to weeks. They are usually seen with the acute form of **bacterial endocarditis.**
57
What is this?
**Roth Spots** are defined as a white centered retinal hemorrhage and are associated with multiple systemic illnesses, most commonly bacterial endocarditis.
58
*List 4 Doppler features of **Constrictive Pericarditis.***
* **Respirator variation in velocities**
* Mitral inflow pattern typically restrictive
* **Inspiration** – **Decreased mitral E velocity**; Decreased pulmonary venous diastolic forward flow; Increased tricuspid E velocity
* **Expiration** – **Increased mitral E velocity**; Increased pulmonary venous diastolic forward flow; Decreased tricuspid E velocity; Decreased or loss of diastolic filling with marked expiratory reversal
* **Tissue Doppler – e’ velocity relative normal or accentuated in constriction (\> 12 cm/sec)**
59
*List 4 of the categories for individuals at higher risk for infective endocarditis.*
1. **Prosthetic heart valve**
2. **Native valve disease**
3. **Congenital heart disease**
4. **IV drug users**
60
* Streptococcus viridians is the least common mouth flora.*
* T or F ?*
F
most common
61
*Discuss the Doppler findings in Cardiac Tamponade in 25 words or less.*
* Respiratory variation in velocities
* **inspiration** - **Decreased** mitral E velocity; **Decreased** pulmonary venous diastolic forward flow; **Increased** tricuspid E velocity
* **Expiration -** reciprocal changes
* Decrease or loss of hepatic vein diastolic filling with marked expiratory reversal
62
Cardiac Tamponade Echo Features
* Pericardial effusion
* RV or RA chamber collapse during **early diastole**
* **IVC plethora:** n cardiac tamponade, IVC plethora (defined as **a decrease in the proximal venal caval diameter by \<50% during deep inspiration**) is often the first echocardiographic sign to appear
* Reciprocal changes in ventricular volumes (septal shift)
* “Swinging Heart” if large effusion
63
*List 4 vascular phenomenon found in patients with infective endocarditis*
* **Petechiae** – subcutaneous dermal flat red spots
* **Splinter hemorrhages** – reddish, thin lines appearing under nails
* **Osler’s nodes** - red, raised, tender lesions on palms and soles
* **Janeway’s lesions** - purplish lesions on the palmer surface of hands and/or feet
64
* Constrictive pericarditis may develop in the aftermath of virtually any pericardial injury or inflammation.*
* T or F ?*
T
65
clinical presentation of constrictive pericarditis
* Dyspnea/Chest pain
* Jugular venous distention
* Edema
* Ascites
**Kussmaul sign** ( A paradoxical rise in jugular venous pressure (JVP) on inspiration, or failure in the appropriate fall of the JVP with inspiration. Causes include: right ventricular infarction, severe right ventricular failure, restrictive cardiomyopathy, constrictive pericarditis, tricuspid stenosis)
**Pulsus Paradoxus** (An abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less that 10 mmHg. Pulsus paradoxus = a drop \> 10mmHg.)
* Hepatosplenomegaly
* Auscultatory findings ( pericardial knock – caused by rapid diastolic filling followed by a prominent halt of flow)
* ECG findings ( **flat or inverted T waves, low voltage QRS complexes** in all leads, A fib, Sinus Tachycardia, Pathologic Q waves, AV or Bundle branch block
66
* The serious pericardium is immediately outside of the myocardium and is a part of the visceral pericardium.*
* T or F ?*
F
67
*Briefly describe the Modified Duke Criteria for Diagnosis of Infective Endocarditis in 25 words or less.*
Definite infective endocarditis - one of the followings:
* culture/histologic examination of a vegetation
* intracardiac abscess specimen
* 2 major criteria
* 1 major criterion & 3 minor criteria
* 5 minor criteria
Possible infective endocarditis - one of the followings:
* 1 major criterion & 1 minor criterion
* 3 minor criteria
68
negative infective endocarditis
69
3 components of Beck’s triad
1. Hypotension/weak pulse due to low CO 2. Muffled heart sound due to fluid around heart 3. Elevated venous pressure/Jagular vein distention
70
Regional tamponade affects selected chamber, typically ________ due to loculated effusion or blood clot post cardiac surgery
Left heart
71
Ventricular respiratory variation is detected when the LV diastolic dimension ______ with inspiration and the RV diastolic dimension ______ with inspiration
Decrease Increase
72
As tamponade increases in severity, the RV diastolic collapse remains throughout the respiratory cycle. T or F ?
T
73
Upon echo, a moderate to severe PE is detected with slight swinging of the heart; an excellent method to rule out RV diastolic collapse with… 1. CFD in the RV 2. Doppler of the AV valves 3. Eye-ball it with 2D echo 4. M-mode at the level of the PE, RVFW and MV
4
74
In order to evaluate the MV and/or TV for respiratory variations, the sonography should \_\_\_\_\_\_
Decrease PW speed to 25mm/s in order to appreciate the variation
75
Respiratory variation is seen as a wavelike motion across the top of Doppler waveforms where the \_\_\_\_\_\_\_
MV waveform decreases with respiration
76
Loculated PE is rare except for patients with \_\_\_\_\_\_\_
Post-op cardiac surgery or metastatic disease
77
A PE associated with metastatic disease frequently has fibrin strands. T or F ?
T \*fibrin strands frequently associated with long standing PE or metastatic diseases
78
A circumferential PE is best visualized from the \_\_\_\_\_\_
PLAX PSAX Sub
79
Tamponade causes a(n) ______ and equalization of diastolic and pericardial pressures; resulting in reduced CO
Elevation
