Cardiac tamponade resident survival guide: Difference between revisions
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❑ Peripheral edema </div>}} | ❑ Peripheral edema </div>}} | ||
{{familytree | | | |!| | | | |}} | {{familytree | | | |!| | | | |}} | ||
{{familytree | | | C01 | | |C01=<div style="float: left; text-align: left | {{familytree | | | C01 | | |C01=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''Begin emergent therapy''' | ||
❑ Place and monitor pulse oximetry <br> | ❑ Place and monitor pulse oximetry <br> | ||
❑ Administer oxygen, if required<br> | ❑ Administer oxygen, if required<br> | ||
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❑ Resuscitate the patient (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>}} | ❑ Resuscitate the patient (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 | {{familytree | | | D01 | |D01=<div style="float: left; text-align: left; width: 40em; padding:1em;">'''Order labs: (Urgent)'''<br> | ||
❑ [[EKG]]<br> | ❑ [[EKG]]<br> | ||
:❑ [[Sinus tachycardia]] | :❑ [[Sinus tachycardia]] | ||
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:❑ Transvalvular flow variation with respiration<br> | :❑ Transvalvular flow variation with respiration<br> | ||
:❑ Dilation of [[IVC]] | :❑ Dilation of [[IVC]] | ||
:❑ Elevated ejection fraction<br> | :❑ Elevated ejection fraction<ref name="Spodick-2003">{{Cite journal | last1 = Spodick | first1 = DH. | title = Acute cardiac tamponade. | journal = N Engl J Med | volume = 349 | issue = 7 | pages = 684-90 | month = Aug | year = 2003 | doi = 10.1056/NEJMra022643 | PMID = 12917306 }}</ref><br> | ||
❑ [[CBC]]<br> | ❑ [[CBC]]<br> | ||
❑ [[Electrolytes]] <br> | ❑ [[Electrolytes]] <br> | ||
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'''Consider additional tests, if necessary''': <br>❑ [[CT]], cardiac [[MRI]] - when echo is inconclusive<br>❑ Thyroid function<br>❑ Serum [[ANA]]/[[RF]] (for [[SLE]])<br>❑ [[Cardiac catheterization]], if necessary</div>}} | '''Consider additional tests, if necessary''': <br>❑ [[CT]], cardiac [[MRI]] - when echo is inconclusive<br>❑ Thyroid function<br>❑ Serum [[ANA]]/[[RF]] (for [[SLE]])<br>❑ [[Cardiac catheterization]], if necessary</div>}} | ||
{{familytree | | | |!| | |}} | {{familytree | | | |!| | |}} | ||
{{familytree | | | E01 | | E01=<div style="float: left; text-align: left | {{familytree | | | E01 | | E01=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''Choice of treatment'''<br>Based on:<br>❑ Echo findings<br>❑ Size and location of fluid<br>❑ Etiology or precipitating events<br>❑ Risk of procedure<br>❑ '''Hemodynamic status'''</div>}} | ||
{{familytree | | | |!| | | |}} | {{familytree | | | |!| | | |}} | ||
{{familytree | | | F01 | | |F01=<div style="float: left; text-align: left; | {{familytree | | | F01 | | |F01=<div style="float: left; text-align: left; 8em; width: 35em; padding:1em;">'''Pre-procedural preparation'''<br>❑ Echo to determine the size, location, and to assess if effusion is loculated or not<br>❑ [[PT]]/[[PTT]]/[[INR]]<br>❑ [[Hemorrhagic stroke resident survival guide#Coagulopathy|Reverse all anticoagulation]]<br>❑ Consult to [[cardiac catheterization]] lab</div>}} | ||
{{familytree | |,|-|^|-|.| |}} | {{familytree | |,|-|^|-|.| |}} | ||
{{familytree | G01 | | G02 | |G01='''Catheter pericardiocentensis with Echo-guidance'''<br>(preferred for hemodynamically unstable patients)<br>|G02=[[Cardiac tamponade resident survival guide#Surgical Drainage|'''Surgical drainage''']]}} | {{familytree | G01 | | G02 | |G01='''Catheter pericardiocentensis with Echo-guidance'''<br>(preferred for hemodynamically unstable patients)<br>|G02=[[Cardiac tamponade resident survival guide#Surgical Drainage|'''Surgical drainage''']]}} | ||
{{familytree | |`|-|v|-|'| | |}} | {{familytree | |`|-|v|-|'| | |}} | ||
{{familytree | | | H01 | H01=<div style="float: left; text-align: left; | {{familytree | | | H01 | H01=<div style="float: left; text-align: left; ; width: 35em; padding:1em;">'''Pericardial fluid analysis & treatment'''<br>❑ [[Gram stain]], [[Microbiological culture|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; | {{familytree | | | I01 | | |I01=<div style="float: left; text-align: left; ; 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; | {{familytree | | | J01 | |J01=<div style="float: left; text-align: left; ; 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/end}} | {{familytree/end}} | ||
Revision as of 20:39, 28 February 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
Cardiac tamponade is a medical emergency characterized by a the compression of the heart by accumulated fluid, pus, blood, clots, or gas in the pericardium.[1]
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Cardiac tamponade is a life-threatening condition and must be treated as such irrespective of the causes.
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
- Radiation
- Uremia
Management
Characterize the symptoms: | |||||||||||||||||
Obtain a detailed history: ❑ Time course of illness
❑ Trauma | |||||||||||||||||
Examine the patient: ❑ Vital signs
❑ Pulsus paradoxus
❑ Jugular vein distention
| |||||||||||||||||
Begin emergent therapy
❑ Place and monitor pulse oximetry or inotropic support (dobutamine, dopamine) | |||||||||||||||||
Order labs: (Urgent) ❑ EKG
❑ Chest X-ray
❑ CBC ❑ BUN 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 | |||||||||||||||||
Surgical Drainage
Consider surgical drainage in the following situations:
- Loculated pericardial effusions
- Recurrent effusion after prior drainage
- Presence of coagulopathy
- When pericardial biopsy is required to make a diagnosis of the underlying cause
Dos
- Always suspect cardiac tamponade in any patient presenting with Beck's triad: hypotension, tachycardia and distended neck veins (or elevated jugular venous pressure).[3] Beck's triad can be absent among patients with cardiac tamponade in the following cases:
- Severe hypotension
- Pericardial adhesions
- Stiffness in the left ventricle much more than that in the right ventricle
- Right ventricule hypertrophy without pulmonary hypertension
- Severe aortic regurgitation
- Atrial septic defect[1]
- 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.
- 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.
- In the case of subclinical uremia, manage the patient by an intensified renal dialysis. If cardiac tamponade is not resolved by dialysis, pericardiocentesis should be attempted.[1]
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
- ↑ 1.0 1.1 1.2 1.3 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) - ↑ 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) - ↑ Sternbach, G.; Beck, C. "Claude Beck: cardiac compression triads". J Emerg Med. 6 (5): 417–9. PMID 3066820.
- ↑ 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)