Cardiac tamponade resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Causes

Causes in Alphabetical Order

• Amyloidosis
• Anticoagulant therapy .
• Aortic dissection
• Bacterial pericarditis
• Bronchogenic cyst
• Cancer
• Chest trauma (both blunt and penetrating)
• Constrictive pericarditis
• Dilated cardiomyopathy
• Dissecting aortic aneurysm
• Dressler syndrome
• During cardiac surgery
• Hypothyroidism
• Malignancy
• Mycobacterium tuberculosis
• Myocardial rupture. Myocardial rupture typically happens in the subacute setting after a myocardial infarction (heart attack), in which the infarcted muscle of the heart thins out and tears. Myocardial rupture is more likely to happen in females, the elderly, patients with hypertension, and individuals without any previouscardiac history who suffer from their first heart attack and are not revascularized with thrombolytic therapy, percutaneous coronary intervention, or withcoronary artery bypass graft surgery. These patients often have single vessel disease without the development of collaterals.
• Penetrating cardiac injury
• Pericarditis
• Physical trauma
• Postpericardiotomy syndrome
• Pyogenic pericarditis
• Rheumatoid pericarditis
• Scrub typhus
• Tuberculous pericarditis
• Uremia
• Uremic pericarditis
• Ventricular aneurysm
• Viral pericarditis

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Management

Shown below is an algorithm showing acute pericarditis management.

Characterize the symptoms: ❑ Prodrome: ♦Fever ♦Malaise ♦Myalgia ❑ Retrosternal or left precordial chest pain: ♦Radiates to trapezius ridge ♦Can be pleuritic ♦Can simulate ischemia ♦Varies with posture

Auscultation: ❑ Pericardial rub ♦Monophasic ♦Biphasic ♦Triphasic

Perform ECG: ❑ Convexly elevated J-ST segment ❑ Determine ECK staging: ♦ Stage I: anterior and inferior concave ST segment elevation. PR segment 7,19 deviations opposite to P polarity ♦ Early stage II: ST junctions return to the baseline, PR deviated ♦ Late stage II: T waves progressively flatten and invert ♦ Stage III: generalised T wave inversions ♦ Stage IV: ECG returns to prepericarditis state

Echocardiography: ❑ Effusion types B- D according to Horowitz classification: ♦ Type A: No effusion ♦ Type B: Separation of epicardium and pericardium (3–16 ml) ♦ Type C 1: Systolic and diastolic separation of epicardium and pericardium (small effusion >16 ml) ♦ Type C 2: Systolic and diastolic separation of epicardium and pericardium with attenuated pericardial motion ♦ Type D: Pronounced separation of epicardium and pericardium with large echo- free space ♦ Type E: Pericardial thickening (>4 mm)

Evidence of pericardial effusion

Order lab tests: ❑ Inflammation markers: ♦ESR ♦CRP ♦LDH ❑ Markers of myocardial lesion: ♦Troponin I ♦CK MB

Large recurrent effusion

Signs of cardiac tamponade

Perform chest X-Ray: ❑ “water bottle” heart shadow