Pericardial Tamponade

Question 1

What are the types of pericardial compression syndromes?

Describe each.

Answer 1

Cardiac tamponade: accumulation of pericardial fluid under pressure.

Constrictive Pericarditis: scarring and consequent loss of elasticity of pericardial sac. May be caused post-operatively.

Effusive-constrictive pericarditis: constriction d/t the thickening of the pericardium itself.

Question 2

Cardiac Tamponade:

-consequences on heart function.

Answer 2

Consequences:

• compression of all cardiac chambers d/t increased pericardial pressure.
• impaired diastolic compliance reducing cardiac filling
• pressure is transmitted to the right ventricle and atrium which causes bulging of interventricular septum and decreased left ventricular compliance and filling.

Question 3

Pericardial Effusion:

• how much fluid is usually in the pericardial sac?
• what are the effects of acute/rapid accumulation of fluid within the pericardial sac? Chronic/slow accumulation?

Answer 3

20-50ml of fluid

Acute/rapid accumulation of fluid gives pericardium no time to adjust, small amount of fluid can cause tamponade.

Chronic/slow accumulation allos for pericardial compliance to increase allowing a larger volume of fluid into the sac.

Question 4

Pericardial Tamponade:

• causes
• sx

Answer 4

Causes:

• malignancy
• infection (viral, bacterial(TB), fungal)
• CV surgery
• Uremia
• SLE, RA, dermatomyositis

Sx:

• dyspnea, tachycardia, tachypnea
• cold, clammy, extremities
• Malignancy = weight loss, fatigue, anorexia
• MI/pericarditisi = chest pain
• CT = joint pain
• Uremia = renal failure
• Medications = drug related lupus
• TB = night sweats, fever

Question 5

Pericardial Tamponade:

• PE findings
• EKG findings
• CXR findings

Answer 5

PE:

• becks triad = increased JVP, hypotension, diminished heart sounds.
• hepatomegaly
• chest wall trauma possibly
• pulsus paradoxxsus (abnormally large decrease in SBP producing a weaker pulse during inspiration; greater than 12mmHg)
• Kussmaul sign (paradoxical increase in venous distension and pressure during inspiration)

EKG findings:

• low voltage
• sinus tachy
• PR depression
• electrical alternans.

CXR: water bottle sign

Question 6

Pericardial Tamponade:

• Dx
• Tx

Answer 6

Dx: 
-clinical 
-get an echo
--pericardial effusion 
--diastolic collapse of right ventricular free wall 
--late diastolic collapse of right atrium 
-swinging of heart in sac?
-LV 
pseudohypertrophy 

-Right heart cath; will find near equilization of the right atrial, right ventricular diastolic, pulmonary arterial diastolic, and pulmonary capillary wedge pressure

Tx:

• Surgery, but while you wait…
• -o2
• -volume expansion with blood, plasma, or saline
• -bed rest with leg elevation
• -inotropic drugs (dobutamine)
• Surgery: pericardiocentesis (fluoroscopically or TTE guided) or pericardial window
• -can be done blind in emergent situation; below xiphoid process, aim towards left shoulder.

-if recurrent: pericardiectomy, pericardial-peritoneal shunt, pericardiodesis (steroids, tetracycline, or antineoplastic drugs instilled into the pericardial space