Cardiac tamponade resident survival guide: Difference between revisions
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===Common Causes=== | ===Common Causes=== | ||
====Acute==== | ====Acute Cardiac Tamponade==== | ||
* [[Idiopathic]] | * [[Idiopathic]] | ||
* [[Aortic dissection|Ascending aortic dissection]] | * [[Aortic dissection|Ascending aortic dissection]] | ||
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* [[Myocardial infarction]] | * [[Myocardial infarction]] | ||
====Chronic==== | ====Chronic Cardiac Tamponade==== | ||
* [[Idiopathic]] | * [[Idiopathic]] | ||
* [[Collagen vascular disease]]s | * [[Collagen vascular disease]]s |
Revision as of 21:56, 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
- Idiopathic
- Ascending aortic dissection
- Iatrogenic (central line insertion, pacemaker insertion, coronary interventions, myocardial biopsy)
- Penetrating trauma
- Myocardial infarction
Chronic Cardiac Tamponade
- Idiopathic
- Collagen vascular diseases
- Malignancy (breast cancer, Kaposi's sarcoma, lung cancer, lymphomas)
- Pericarditis
- Radiation
- Tuberculosis
- Uremia[2]
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 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).[4] 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.[2] 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) - ↑ 2.0 2.1 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) - ↑ 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.
- ↑ 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)