Pericardiocentesis

Question 1

Cardiac Tamponade

3 possible pericardial compression syndromes. What are they and describe them.

Answer 1

1. Cardiac tamponade
   - accumulation of pericardial fluid under pressure and may be acute or subacute
2. Constrictive pericarditis
   - scarring and consequent loss of elasticity of the pericardial sac
3. Effusive-constrictive pericarditis
   - constrictive physiology with a coexisting pericardial effusion
   - Elevated wedge and Rt sided pressures s/p drainage

Question 2

Cardiac Tamponade

1. Compression of all cardiac chambers due to what?

2. Pericardium has some compliance with increased pressure, but once that is exceeded it begins to impair what? 2

3. Much of the pressure is transmitted to the what?

4. which causes what? 2

Answer 2

1. increased pericardial pressure

2.

-diastolic compliance,

-reducing cardiac filling

3. Rt Vent/Atrium (lower pressure systems)

4.

-bulging of interventricular septum

-decreased Lt ventricular compliance and filling

Question 3

Pericardial Effusion

1. Pericardial Effusion typically has what?
2. Acuity of fluid accumulation plays a large role in pericardial compliance. Describe the differences in slow and rapid accumulation?
3. In what situation is tamponade physiology able to occur?

Answer 3

1. Pericardium typically has 20-50 ml of fluid
2. Acuity of fluid accumulation plays a large role in pericardial compliance
   - Rapid accumulation (trauma) gives pericardium no time to adjust, therefore a small amount of fluid can cause tamponade
   - Slow accumulation allows pericardial compliance to increase allowing a larger volume of fluid into sac
3. However, when pericardial pressures > Rt ventricular pressure tamponade physiology can occur

Question 4

Causes of pericardial tamponade

15

Answer 4

1. Malignancy
2. HIV infection
3. Infection - Viral, bacterial (tuberculosis), fungal
4. Drugs - Hydralazine, procainamide, isoniazid, minoxidil
5. Postcoronary intervention (ie, coronary dissection and perforation)
6. Trauma
7. Cardiovascular surgery (postoperative pericarditis)
8. Postmyocardial infarction (free wall ventricular rupture, Dressler syndrome)
9. Connective tissue diseases - Systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis
10. Radiation therapy
11. Iatrogenic - After sternal biopsy, transvenous pacemaker lead implantation, pericardiocentesis, or central line insertion
12. Uremia
13. Idiopathic pericarditis
14. Complication of surgery at the esophagogastric junction such as antireflux surgery
15. Pneumopericardium (due to mechanical ventilation or gastropericardial fistula)

Question 5

Symptoms

1. MC symptoms? 3
2. Extremity symptoms?
3. Malignancy would cause? 3
4. CHest pain? 2
5. In connective tissue disorer you will have associated? 1
6. Renal failure will show? 1
7. Medications can cause? 1
8. Recent procedures such as? 2
9. TB would have associated? 2
10. Radiation? 1

Answer 5

1.

• Dyspnea,
• tachycardia,
• tachypnea
  2. Cold, clammy extremities
  3. Malignancy –
• weight loss,
• fatigue,
• anorexia
  3. Chest pain –
• pericarditis,
• MI
  4. Joint pain – connective tissue
  5. Renal failure – uremia
  6. Medications – drug related lupus
  7. Recent procedure – pacemaker, central line
  8. TB –
• night sweats,
• fever
  9. Radiation – cancer history

Question 6

Physical Exam Findings

1. What is Beck’s triad?
2. Other symptoms? 5

Answer 6

1. Beck’s Triad –
   - increased JVP,
   - hypotension,
   - diminished heart sounds

2.

• Hepatomegaly
• Evidence of chest wall trauma
• Pulsus paradoxsus > 12 mm Hg
• Kussmaul sign - paradoxical increase in venous distention and pressure during inspiration
• Abolished y descent

Question 7

Diagnosis on ECG of pericardial tamponade? 4

Answer 7

EKG –

1. low voltage,
2. sinus tach,
3. PR depression,
4. electrical alternans

Question 8

Pericardial tamponade CXR findings? 2

Answer 8

1. enlarge cardiac silhouette,
2. water bottle shaped heart

Question 9

Echocardiogram (tamponade is clinical diagnosis)

What will it show for tamponade? 5

Answer 9

1. Pericardial effusion
2. Early diastolic collapse of the right ventricular free wall
3. Late diastolic compression/collapse of the right atrium
4. Swinging of the heart in its sac
5. LV pseudohypertrophy

Question 10

Dx cardiac tamponade

1. If patient is stable and diagnosis is in doubt can perform a what?
2. To measure what?
3. In tamponade, near equalization (within 5 mm Hg) of what pressures? 4
4. Rt atrial pressure tracings show abolished what?

Answer 10

1. Rt Heart Catheterization
2. Rt heart catheterization to measure Rt sided pressures

3.

• right atrial,
• right ventricular diastolic,
• pulmonary arterial diastolic
• pulmonary capillary wedge pressure
  4. systolic y descent

Question 11

Tamponade: What to do while your waiting on CT Surgery…? 4

Answer 11

1. Oxygen
2. Volume expansion with blood, plasma, or saline to maintain adequate intravascular volume
3. Bed rest with leg elevation: This may help increase venous return.
4. Inotropic drugs (i.e. dobutamine): Choose inotropes that do not increase systemic vascular resistance while increasing cardiac output.

Question 12

Which ionotropes should you use for tamponade?

Answer 12

Choose inotropes that do not increase systemic vascular resistance while increasing cardiac output.

Question 13

Tamponade tx? 2

Answer 13

1. Pericardiocentesis
2. Pericardial window

Question 14

1. Pericardiocentesis: Can we guided how? 2
2. Pericardial window: What is this?

Answer 14

1. Pericardiocentesis
   - can be fluoroscopically or TTE guided
2. Pericardial window
   - involves the surgical opening of a communication between the pericardial space and the intrapleural space

Question 15

Recurrent effusion: how should we treat? 3

Answer 15

1. Pericardectomy
2. Pericardial-peritoneal shunt
3. Pericardiodesis

Question 16

What drugs are involved in Pericardiodesis? 3

Answer 16

1. corticosteroids,
2. tetracycline, or
3. antineoplastic drugs

can be instilled into the pericardial space sclerosing the pericardium

Question 17

Tamponade tx: No one shows up and cardiac arrest is called

1. MANAGEMENT?
2. How do we do this?
3. When performed emergently, this procedure is associated with a reported mortality rate of what and a complication rate of what?

Answer 17

1. Emergency subxiphoid percutaneous drainage
2. A 16- or 18-gauge needle is inserted at an angle of 30-45° to the skin, near the left xiphocostal angle, aiming towards the left shoulder
3. approximately 4% and a complication rate of 17%

Question 18

Pericardiocentesis

1. Pericardiocentesis is the definitive therapy to do what?
2. Commonly performed where?
3. How will you verify your location?

Answer 18

1. remove the excessive fluid
2. in the cath lab but may be done ‘blind’ in an intensive care or emergency department environment
3. Attach limb leads to verify your location (“sign of weakness but if you have the time…do it” said the CV surgeon: the ED PA says “the STANDARD OF CARE IS – DO IT”)