Cardiac tamponade resident survival guide: Difference between revisions
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{{familytree | G01 | | G02 | |G01=❑ '''Catheter pericardiocentensis with echo-guidance'''|G02=❑ '''Surgical drainage'''}} | {{familytree | G01 | | G02 | |G01=❑ '''Catheter pericardiocentensis with echo-guidance'''|G02=❑ '''Surgical drainage'''}} | ||
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{{familytree | | | H01 | H01=<div style="float: left; text-align: left; ; width: 35em; padding:1em;">''' | {{familytree | | | H01 | H01=<div style="float: left; text-align: left; ; width: 35em; padding:1em;">'''Send the pericardial fluid for analysis:'''<br>❑ [[Gram stain]] <br> ❑ [[Microbiological culture|culture]]<br>❑ [[Cytology]]<br>❑ AFB stain & mycobacteria culture<br>❑ [[Polymerase chain reaction]] for [[CMV]]</div>}} | ||
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{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; ; width: 35em; padding:1em;"> | {{familytree | | | J01 | |J01=<div style="float: left; text-align: left; ; width: 35em; padding:1em;"> | ||
❑ Monitor vital signs frequently<br> | |||
❑ Repeat echocardiography<br> | |||
❑ Determine and treat the underlying cause<br> | |||
❑ Monitor the patient for complications | |||
:❑ Acute [[left ventricular failure]] | |||
:❑ [[Pulmonary edema]] | |||
:❑ [[Pneumothorax]] | |||
:❑ [[Arrhythmia]]s | |||
:❑ Perforation of cardiac chambers | |||
:❑ [[Hemothorax]]</div>}} | |||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 19:25, 1 March 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
- Idiopathic
- Ascending aortic dissection
- Iatrogenic (central line insertion, pacemaker insertion, coronary interventions, myocardial biopsy)
- Penetrating trauma
- Myocardial infarction[2]
Subacute Cardiac Tamponade
- Idiopathic
- Collagen vascular diseases
- Malignancy (breast cancer, Kaposi's sarcoma, lung cancer, lymphomas)
- Medications (cyclosporine, anticoagulants, thrombolytics)
- Pericarditis
- Radiation
- Tuberculosis
- Uremia[2]
Management
Characterize the symptoms: | |||||||||||||||||
Obtain a detailed history: ❑ Time course of illness
❑ Medications | |||||||||||||||||
Examine the patient: ❑ Vital signs
❑ Pulsus paradoxus
| |||||||||||||||||
Consider alternative diagnoses: ❑ For acute chest pain and hypotension ❑ For the subacute symptoms ❑ For pulsus paradoxus | |||||||||||||||||
Order tests: (Urgent) ❑ EKG
❑ Chest X-ray
❑ CBC Consider additional tests, if necessary: ❑ Cardiac MRI (when echocardiography is inconclusive) ❑ Cardiac catheterization | |||||||||||||||||
The patient needs drainage of the pericardial fluid | |||||||||||||||||
Does the patient have any of the following? ❑ Low volume of pericardial fluid | |||||||||||||||||
❑ Catheter pericardiocentensis with echo-guidance | ❑ Surgical drainage | ||||||||||||||||
Send the pericardial fluid for analysis: ❑ Gram stain ❑ culture ❑ Cytology ❑ AFB stain & mycobacteria culture ❑ Polymerase chain reaction for CMV | |||||||||||||||||
❑ Monitor vital signs frequently
| |||||||||||||||||
Dos
- 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 is typical in acute cardiac tamponade but is usually absent in chronic cases.
- Measure pulsus paradoxus whenever cardiac tamponade is suspected. Pulsus paradoxus is the reduction in systolic blood pressure by ≥ 10 mmHg during inspiration.[2] Pulsus paradoxus 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]
- Suspect an infectious or inflammatory etiology when fever is present.[2]
- Make sure the drainage of pericardial effusion is gradual and slow to avoid the precipitation of pulmonary edema.
- Consider echocardiography as the primary modality of choice due to its high specificity and sensitivity, low cost and lack of radiation. Order s CT scan or a cardiac MRI when echocardiography is inconclusive.[4]
- Consider 2D and doppler echocardiography prior to discharging the p[atient to confirm total removal or detect reaccumulation of pericardial fluid.
- Consider surgical drainage in aortic dissection and myocardial rupture.[5]
- When surgical drainage is indicated but the patient has severe hypotension prohibiting the induction of anesthesia, perform pericardiocentesis in the operating room before surgery.[5]
- 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) - ↑ 2.0 2.1 2.2 2.3 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) - ↑ Sternbach, G.; Beck, C. "Claude Beck: cardiac compression triads". J Emerg Med. 6 (5): 417–9. PMID 3066820.
- ↑ 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) - ↑ 5.0 5.1 Schiavone WA (2013). "Cardiac tamponade: 12 pearls in diagnosis and management". Cleve Clin J Med. 80 (2): 109–16. doi:10.3949/ccjm.80a.12052. PMID 23376916.
- ↑ 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)