Pericardium

Question 1

Causes of pericarditis:

Answer 1

Idiopathic (25%)

Malignant (25%)

Infective
- Viral
- TB
- Staph, strep
- Rheumatic fever

Trauma
- Post-pericardiotomy
- Radiation

Drug
- Hypersensitivity

Dressler’s (post-AMI)

Systemic disease
- SLE
- Rheumatoid
- Myxoedema
- Uraemia
- IBD

Question 2

ECG stages of pericarditis:

Answer 2

Stage 1: hours - days
- Typical findings
Stage 2: days - weeks
- Normalisation
Stage 3: days - weeks
- TWI
Stage 4: 3 months
- Normalises again

Question 3

Management of simple pericarditis:

Answer 3

• Ix cause
• Check no:
  –> Myocarditis
  –> Effusion

High-dose NSAIDS eg. Ibuprofen 800 TDS, aspirin 1g TDS (with PPI)
- 7-10 days

PLUS

Colchicine 500microg BD (daily if <70kg)
- 3 months

Question 4

Physiological volume of pericardial fluid?

Answer 4

35ml

(can accomodate 200ml acutely, 2L chronically)

Question 5

Clinical features of tamponade:

Answer 5

Beck’s triad (not common!)
- JVP
- Muffled heart sounds
- Hypotension

Dyspnoea (90%)
Pulsus paradoxus (80%)
Tachycardia (70%)

Low ECG amplitude
Electrical alternans

‘Globular’ heart on CXR

Question 6

TTE findings in tamponade:

Answer 6

Long axis and 4-chamber

• Effusion
• ‘Swinging’ heart
• Systolic RA collapse
• Diastolic RV collapse
• IVC plethora (>1.5-2.1cm) with minimal resp variation (<50%)

Question 7

Normal IVC diameter and degree of collapse with inspiration

Answer 7

<2.1cm

50%

Question 8

Management of crashing non-traumatic tamponade patient:

Answer 8

Optimise preload:
- Fluid bolus
- Avoid PPV

Drain the pericardium
- Needle pericardiocentesis
–> Cath lab (ideal)
–> ED USS
–> Blind
- OT pericardiotomy
- Thoracotomy

No role for inotropes
No role for CPR

Question 9

ED pericardiocentesis techniques:

Answer 9

18G extra-long cannula on 20-30ml syringe

APPROACHES:

• 1- SUBXIPHOID
  BLIND
  –> L of xiphi
  –> 45degree approach towards L scapula
• 2- PARASTERNAL
  Safest
  –> 5th IC space, adjacent to sternum
• 3- APICAL
  –> 1cm below apex beat

Leave cannula in situ (or insert pigtail via Seldinger). 3-way tap –> asp PRN.

Question 10

Classify ‘size’ of pericardial effusion on POCUS:

Answer 10

In diastole

<10mm: Small (up to 100ml)
10-20 Mod
>20 Large (>500ml)

Question 11

Management of a traumatic tamponade:

Answer 11

Cardiothoracics!

If periarrest/arrest: ED thoractomy

Needle pericardiocentesis ONLY has a limited role as temporising measure when CTx not immediately available (but available soon)