Pericardial Tamponade & Pericardiocentesis; Pleural Effusion

Question 1

Cardiac Tamponade

Answer 1

Accumulation of pericardial fluid under pressure

May be acute or subacute

Compression of all cardiac chambers due to increased pericardial pressure

Most of the pressure transmitted to R Vent/Atrium - causes bulging of interventricular septum with decreased L vent compliance and filling

Question 2

Constrictive Pericarditis

Answer 2

Scarring and consequent loss of elasticity of pericardial sac

Question 3

Effusive-Constrictive Pericarditis

Answer 3

Constrictive physiology with coexisting pericardial effusion

Elevated wedge and right-sided pressure after drainage

Question 4

Pericardial Space Fluid

Answer 4

Pericardium typically has 20-50 ml fluid

Amount over time of fluid accumulation really affects pericardial compliance

• rapid = no time to adjust
• slow = allows pericardial compliance

When pericardial pressures > R ventricular pressure tamponade physiology occur

Question 5

Chest Pain and Pericardial Effusion

Answer 5

Chest pain decreases as fluid collection increases

Fluid accumulation pushes the two linings further apart and prevents rubbing

Question 6

Beck’s Triad

Answer 6

Increased JVP

HOTN

Diminished heart sounds

Question 7

Pulsus Paradoxsus

Kussmaul Sign

Answer 7

Pulsus Paradoxsus = decrease in BP and pulse during inspiration >12 mmHg (decrease isn’t abnormal, just the amount of decreases

Kussmaul sign = Paradoxicfal increases in JVP on inspiration due to impaired right ventricular filling

Question 8

Pericardial Effusion EKG

Answer 8

Low voltage

Sinus tach

PR Depression

Electrical alternans - may disappear as compression of heart increases

Question 9

Pericardial Effusion CXR

Answer 9

Enlarged cardiac silhouette

Water-bottle shaped heart

Question 10

Pericardial Effusion Echocardiogram

Answer 10

Pericardial effusion

Early diastolic collapse of R ventricular free wall

Later diastolic compression/collapse of the R atrium

Swinging of the heart in its sac

LV pseudohypertrophy

Question 11

Pericardial Effusion Stabilization

Answer 11

Oxygen

Volume expansion - intravascular

Bed rest with leg elevation

Inotropic drugs (Dobutamine) - do not increase PVR, but do increase CO

Question 12

Pericardiodesis

Answer 12

Corticosteroid, tetracycline, or antineoplastic drugs instilled into the pericardial space to sclerose the pericardium

Used to treat recurrent effusions

Question 13

3 Mechanisms of Fluid Accumulation in Pleural Space

Answer 13

Increased drainage of fluids

Increased production of fluids by cells in the space

Decreased drainage of fluid from space

Question 14

Intrapulmonary Pressure

Answer 14

Pressure within the alveoli

With inspiration, chest expansion causes intrapulmonary pressure to become more negative

-This causes air to be sucked inot the lungs

Question 15

Intrapleural Pressure

Answer 15

Negative pressure creases in pleural space by chest enlargement and lung recoil during normal inspiration

Negatvie pressure may be lost if fluid collects in the pleural space

• lungs cannot expand fully

Question 16

Normal Pleural Fluid Levels

Answer 16

Up to 25 ml fluid normally present

This amount is usually not detectable on CXR

Question 17

Main Causes of Pleural Effusion

Answer 17

CHF

Liver Failure

Infection

Atelectasis

Cancer

Trauma

Question 18

Hemothorax

Answer 18

Blood accumulation in pleural space

Usually a result of chest injury

Blood vessel rupture into pleural space, aortic bulge with leaking blood into the pleural space

Can occur as a result of bleeding from the ribs, chest wall, pleura, and lung

Question 19

Pleural Fluid Types

Transudate

Exudate

Empyema

Chyle

Hemothorax

Answer 19

Transudate: Serum without fluid

Exudate: Protein in fluid - usually infectious, inflammation, cancer

Empyema: Pus

Chyle: Lymph fluid

Hemothorax: Blood

Question 20

Imaging of Pericardial Effusion

Answer 20

Need 250 mL fluid present to see on PA CXR

Lateral decubits to confirm fluid