Cardiac tamponade resident survival guide: Difference between revisions
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{{familytree | | | C01 | | |C01=<div style="float: left; text-align: left; height: 10em; width: 35em; padding:1em;">'''Emergent therapy''' | {{familytree | | | C01 | | |C01=<div style="float: left; text-align: left; height: 10em; width: 35em; padding:1em;">'''Emergent therapy''' | ||
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❑ Pulse oximetry <br> ❑ Administer oxygen, if required<br> ❑ Large bore IV lines<br> ❑ Consult to ICU<br> ❑ Fluid rescuscitation (blood, plasma, dextran or saline)<br> or inotropic support ([[dobutamine]], [[dopamine]])</div>}} | ❑ Pulse oximetry <br> ❑ Administer oxygen, if required<br> ❑ Large bore IV lines<br> ❑ Consult to ICU<br> ❑ Fluid rescuscitation (blood, plasma, dextran or saline)<ref name="Kerber-1982">{{Cite journal | last1 = Kerber | first1 = RE. | last2 = Gascho | first2 = JA. | last3 = Litchfield | first3 = R. | last4 = Wolfson | first4 = P. | last5 = Ott | first5 = D. | last6 = Pandian | first6 = NG. | title = Hemodynamic effects of volume expansion and nitroprusside compared with pericardiocentesis in patients with acute cardiac tamponade. | journal = N Engl J Med | volume = 307 | issue = 15 | pages = 929-31 | month = Oct | year = 1982 | doi = 10.1056/NEJM198210073071506 | PMID = 7110273 }}</ref> <br> or inotropic support ([[dobutamine]], [[dopamine]])</div>}} | ||
{{familytree | | | |!| | |}} | {{familytree | | | |!| | |}} | ||
{{familytree | | | D01 | |D01=<div style="float: left; text-align: left; height: 30em; width: 40em; padding:1em;">'''Urgent Labs:'''<br> ❑ [[EKG]]<br>♦ [[Sinus tachycardia]], [[electrical alternans]], low QRS voltages<br> ❑ Chest X-ray<br>♦ Enlarged cardiac silhouette<br>♦ clear lung fields <br> ❑ [[Echocardiography]]<br>♦ [[Pericardial effusion]]<br>♦ Cardiac chamber collapse (right atrium and ventricle)<br>♦ Flow variation<br>♦ Dilation of [[IVC]]<br> ❑ [[CBC]]<br>❑ [[Electrolytes]] <br> ❑ [[BUN]] <br> ❑ [[Creatinine]] | {{familytree | | | D01 | |D01=<div style="float: left; text-align: left; height: 30em; width: 40em; padding:1em;">'''Urgent Labs:'''<br> ❑ [[EKG]]<br>♦ [[Sinus tachycardia]], [[electrical alternans]], low QRS voltages<br> ❑ Chest X-ray<br>♦ Enlarged cardiac silhouette<br>♦ clear lung fields <br> ❑ [[Echocardiography]]<br>♦ [[Pericardial effusion]]<br>♦ Cardiac chamber collapse (right atrium and ventricle)<br>♦ Flow variation<br>♦ Dilation of [[IVC]]<br> ❑ [[CBC]]<br>❑ [[Electrolytes]] <br> ❑ [[BUN]] <br> ❑ [[Creatinine]] | ||
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{{familytree | | | H01 | H01=<div style="float: left; text-align: left; height: 8em; width: 35em; padding:1em;">'''Pericardial fluid analysis & treatment'''<br>❑ Gram stain, culture<br>❑ Cytology<br>❑ AFB stain & mycobacteria culture<br>❑ [[Polymerase chain reaction]] - [[CMV]]<br>❑ Initiate treament of underlying diseases</div>}} | {{familytree | | | H01 | H01=<div style="float: left; text-align: left; height: 8em; width: 35em; padding:1em;">'''Pericardial fluid analysis & treatment'''<br>❑ Gram stain, culture<br>❑ Cytology<br>❑ AFB stain & mycobacteria culture<br>❑ [[Polymerase chain reaction]] - [[CMV]]<br>❑ Initiate treament of underlying diseases</div>}} | ||
{{familytree | | | |!| | |}} | {{familytree | | | |!| | |}} | ||
{{familytree | | | I01 | | |I01=<div style="float: left; text-align: left; height: 8em; width: 35em; padding:1em;">'''Manage complications'''<br>❑ Acute [[left ventricular failure]] + [[pulmonary edema]]<br>❑ [[Pneumothorax]]<br>❑ [[Ventricular arrhythmia]]s<br>❑ Perforation of cardiac chambers<br>❑ Hemothorax</div>}} | {{familytree | | | I01 | | |I01=<div style="float: left; text-align: left; height: 8em; width: 35em; padding:1em;">'''Manage complications'''<br>❑ Acute [[left ventricular failure]] + [[pulmonary edema]]<br>❑ [[Pneumothorax]]<br>❑ [[Ventricular arrhythmia]]s<br>❑ Perforation of cardiac chambers<br>❑ [[Hemothorax]]</div>}} | ||
{{familytree | | | |!| |}} | {{familytree | | | |!| |}} | ||
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; height: 12em; width: 35em; padding:1em;">'''Monitoring'''<br>❑ Continuous [[telemetry]]<br>❑ Frequent vitals<br>❑ Daily monitoring of:<br>♦ Patency of the catheter<br>♦ Rate of drainage<br>'''Note''' <br>Leave catheter in situ for 24 - 48 hours or when the volume of drainage is <25 ml/day</div>}} | {{familytree | | | J01 | |J01=<div style="float: left; text-align: left; height: 12em; width: 35em; padding:1em;">'''Monitoring'''<br>❑ Continuous [[telemetry]]<br>❑ Frequent vitals<br>❑ Daily monitoring of:<br>♦ Patency of the catheter<br>♦ Rate of drainage<br>'''Note''' <br>Leave catheter in situ for 24 - 48 hours or when the volume of drainage is <25 ml/day</div>}} |
Revision as of 16:51, 30 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2] Ayokunle Olubaniyi, M.B,B.S [3]
Definition
This is a medical emergency which involves a slow or rapid compression of the heart due to the accumulation of fluid, pus, blood, clots, or gas in the pericardium, as a result of effusion, trauma, or rupture of the heart.[1] It is suspected based on history, physical examination, and chest imaging findings, but it is confirmed based on the clinical response observed during or post-pericardial fluid drainage.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Any cause of pericardial effusion capable of compromising the hemodynamic status of a patient is potentially life threatening.
Common Causes
Acute Cardiac Tamponade
- Ascending aortic dissection
- Iatrogenic - central line insertion, pacemaker insertion, coronary interventions, myocardial biopsy
- Penetrating trauma
- Post myocardial infarction treatment - heparin, thrombolytics
Subacute Cardiac Tamponade
- Collagen vascular diseases
- Idiopathic
- Malignancy - breast cancer, Kaposi's sarcoma, lung cancer, lymphomas
- Pericarditis
- Virus - coxsackie virus, echovirus, CMV
- Bacteria - pneumococcus, streptococcus, staphylococcus
- Fungus - blastomyces, cryptococcus, histoplasma, pneumocystis carinii
- Tuberculous
Management
Characterize the symptoms:
Or as symptoms of the following complications
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Patient evaluation:
❑ Obtain a detailed history: ❑ Examine the patient: ❑ General- distended neck veins (↑JVP) ❑ Vitals ♦ Tachycardia, tachypnea, hypotension ❑ Cardiopulmonary ♦ Clear lungs ♦ Distant (muffled) heart sounds ♦ Pericardial friction rub ❑ Limbs - peripheral edema Note ♦ Measure BP and response to inspiration (pulsus paradoxus) ♦ Bradycardia (especially in uremia or hypothyroidism) ♦ Beck's triad - Low arterial blood pressure (hypotension), distant (muffled) heart sounds & distended neck veins (↑JVP)[2] | ||||||||||||||||||||||||
Emergent therapy
❑ Pulse oximetry ❑ Administer oxygen, if required ❑ Large bore IV lines ❑ Consult to ICU ❑ Fluid rescuscitation (blood, plasma, dextran or saline)[3] or inotropic support (dobutamine, dopamine) | ||||||||||||||||||||||||
Urgent Labs: ❑ EKG ♦ Sinus tachycardia, electrical alternans, low QRS voltages ❑ Chest X-ray ♦ Enlarged cardiac silhouette ♦ clear lung fields ❑ Echocardiography ♦ Pericardial effusion ♦ Cardiac chamber collapse (right atrium and ventricle) ♦ Flow variation ♦ Dilation of IVC ❑ CBC ❑ Electrolytes ❑ BUN ❑ Creatinine Consider additional tests, if necessary: ❑ CT, cardiac MRI - when echo is inconclusive ❑ Thyroid function ❑ Serum ANA/RF (for SLE) ❑ Cardiac catheterization, if necessary | ||||||||||||||||||||||||
Choice of treatment Based on: ❑ Echo findings ❑ Size and location of fluid ❑ Etiology or precipitating events ❑ Risk of procedure ❑ Hemodynamic status | ||||||||||||||||||||||||
Pre-procedural preparation ❑ Echo to determine the size, location, and to assess if effusion is loculated or not ❑ PT/PTT/INR ❑ Reverse all anticoagulation ❑ Consult to cardiac catheterization lab | ||||||||||||||||||||||||
Catheter pericardiocentensis with Echo-guidance (preferred for hemodynamically unstable patients) | Surgical drainage | |||||||||||||||||||||||
Pericardial fluid analysis & treatment ❑ Gram stain, culture ❑ Cytology ❑ AFB stain & mycobacteria culture ❑ Polymerase chain reaction - CMV ❑ Initiate treament of underlying diseases | ||||||||||||||||||||||||
Manage complications ❑ Acute left ventricular failure + pulmonary edema ❑ Pneumothorax ❑ Ventricular arrhythmias ❑ Perforation of cardiac chambers ❑ Hemothorax | ||||||||||||||||||||||||
Monitoring ❑ Continuous telemetry ❑ Frequent vitals ❑ Daily monitoring of: ♦ Patency of the catheter ♦ Rate of drainage Note Leave catheter in situ for 24 - 48 hours or when the volume of drainage is <25 ml/day | ||||||||||||||||||||||||
Dos
- Always suspect cardiac tamponade in any patient presenting with hypotension, tachycardia and distended neck veins (or elevated jugular venous pressure).
- Always measure pulsus paradoxus whenever you suspect cardiac tamponade. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps in the making a diagnosis of cardiac tamponade.[4] Pulsus paradoxus is the reduction in systolic blood pressure by ≥ 10 mmHg during inspiration.
- Consider the intrapericardial pressure more than the volume of the pericardial fluid in the management of cardiac tamponade.
- The drainage of pericardial effusion should be gradual and slow to avoid the precipitation of pulmonary edema.
- Echocardiography is the primary modality of choice, considering its high specificity and sensitivity, low cost and lack of radiation. CT and cardiac MRI are indicated when echocardiography is inconclusive.[5]
- Consider 2D and doppler echocardiography prior to discharge to confirm total removal or detect reaccumulation of pericardial fluid.
- Consider pericardiocentesis in all cases except aortic dissection or myocardial rupture, in which removal of fluid should be done in preparation for a surgical repair.
Don'ts
- Never delay treatment whenever you suspect cardiac tamponade.
- Avoid diuretics because it may worsen the central venous pressure.
- Avoid placing pericardial fluid drainage catheter in situ for > 3 days.
- Avoid the subcostal approach of pericardiocentesis if coagulopathy is present. Iatrogenic injuries to the liver may be life-threatening.
- Avoid positive pressure mechanical ventilation. It may further reduce cardiac filling.[6]
- The use of inotropic agents for hemodynamic support should not be a substitute or cause a delay to pericadiocentesis.
- Avoid the use of beta blockers in order to preserve the compensatory adrenergic response to pericardial effusion which include tachycardia and increased contractility.
References
- ↑ Spodick, DH. (2003). "Acute cardiac tamponade". N Engl J Med. 349 (7): 684–90. doi:10.1056/NEJMra022643. PMID 12917306. Unknown parameter
|month=
ignored (help) - ↑ Sternbach, G.; Beck, C. "Claude Beck: cardiac compression triads". J Emerg Med. 6 (5): 417–9. PMID 3066820.
- ↑ Kerber, RE.; Gascho, JA.; Litchfield, R.; Wolfson, P.; Ott, D.; Pandian, NG. (1982). "Hemodynamic effects of volume expansion and nitroprusside compared with pericardiocentesis in patients with acute cardiac tamponade". N Engl J Med. 307 (15): 929–31. doi:10.1056/NEJM198210073071506. PMID 7110273. Unknown parameter
|month=
ignored (help) - ↑ Roy, CL.; Minor, MA.; Brookhart, MA.; Choudhry, NK. (2007). "Does this patient with a pericardial effusion have cardiac tamponade?". JAMA. 297 (16): 1810–8. doi:10.1001/jama.297.16.1810. PMID 17456823. Unknown parameter
|month=
ignored (help) - ↑ Maisch, B.; Seferović, PM.; Ristić, AD.; Erbel, R.; Rienmüller, R.; Adler, Y.; Tomkowski, WZ.; Thiene, G.; Yacoub, MH. (2004). "Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology". Eur Heart J. 25 (7): 587–610. doi:10.1016/j.ehj.2004.02.002. PMID 15120056. Unknown parameter
|month=
ignored (help) - ↑ Little, WC.; Freeman, GL. (2006). "Pericardial disease". Circulation. 113 (12): 1622–32. doi:10.1161/CIRCULATIONAHA.105.561514. PMID 16567581. Unknown parameter
|month=
ignored (help)