Cardiac tamponade resident survival guide: Difference between revisions
Line 52: | Line 52: | ||
{{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''' | ||
---- | ---- | ||
❑ Pulse oximetry <br> ❑ Administer oxygen, if | ❑ 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>}} | ||
{{familytree | | | |!| | |}} | {{familytree | | | |!| | |}} | ||
{{familytree | | | D01 | |D01=}} | {{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]] | ||
---- | |||
'''Consider additional tests, if necessary''': <br>❑ [[CT]], cardiac [[MRI]] - when echo is inconclusive<br>❑ Thyroid function<br>❑ Serun ANA (SLE)</div>}} | |||
{{familytree | | | |!| | |}} | {{familytree | | | |!| | |}} | ||
{{familytree | | | E01 | | E01=}} | {{familytree | | | E01 | | E01=<div style="float: left; text-align: left; height: 10em; 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=}} | {{familytree | | | F01 | | |F01=}} |
Revision as of 17:35, 28 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.
Common Causes
Acute Cardiac Tamponade
- Ascending aortic dissection
- Iatrogenic - central line insertion, pacemaker insertion, coronary interventions, myocardial biopsy
- Penetrating trauma
- Post myocardial infarction treatments - heparin, thrombolytics
Subacute Cardiac Tamponade
- Collagen vascular diseases
- Idiopathic
- Malignancy - breast, Kaposi's sarcoma, lung, lymphomas
- Pericarditis
- Viral - coxsachie, echo, CMV
- Bacterial - pneumococcus, streptococcus, staphylococcus
- Fungal - blastomyces, cryptococcus, histoplasma, pneumocystis carinii
- Tuberculous
Management
Characterize the symptoms:
Or as a feature of a complication
| |||||||||||||||||||||||||
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) | |||||||||||||||||||||||||
Emergent therapy
❑ Pulse oximetry ❑ Administer oxygen, if required ❑ Large bore IV lines ❑ Consult to ICU ❑ Fluid rescuscitation (blood, plasma, dextran or saline) 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 ❑ Serun ANA (SLE) | |||||||||||||||||||||||||
Choice of treatment Based on: ❑ Echo findings ❑ Size and location of fluid ❑ Etiology or precipitating events ❑ Risk of procedure ❑ Hemodynamic status | |||||||||||||||||||||||||
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.
- 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.
- Consider 2D and doppler echocardiography prior to discharge to confirm total removal or detect reaccumulation of pericardial fluid.
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.
- The use of inotropic agents for hemodynamic support should not be a substitute or cause a delay to pericadiocentesis.