Cardiac tamponade
- 3. Cardiac tamponade is a clinical syndrome caused by accumulation of fluid in pericardial space, resulting in reduced ventricular filling and subsequent haemodynamic compromise. The condition is a medical emergency.
- 4. Pericardium is composed of 2 layers Thicker outer fibrous layer is parietal percardium Thinner inner serous layer is visceral pericardium Pericardial space normally contains 20 - 50 ml of fluid
- 5. Three phases of haemodynamic changes in tamponade PHASE 1: Accumulation of pericardial fluid impairs relaxation and filling of ventricles, requiring a high filling pressure. Left and right ventricular filling pressures are higher than the intrapericardial pressure.
- 6. PHASE 2: Pericardial pressure increases above the ventricular filling pressure ,resulting in reduced cardiac output. PHASE 3: Further decrease in cardiac output occurs due to equilibration of pericardial and left ventricular filling pressures.
- 7. Malignant diseases – most common cause (30-60%) Uremia(10-15%) Idiopathic pericarditis(5-15%) Infectious diseases(5-10%) CTD (2-6%) Dressler or post pericardiotomy syndrome(1- 2%)
- 8. Pericarditis caused by HIV Infections- viral, bacterial(TB),fungal Drugs- hydralazine, procainamide, INH, minoxidil Post coronary intervention- coronary dissection and perforation Post cardiac percutaneous procedures Trauma to chest Cardiovascular surgery Post MI infarction- free wall ventricular rupture and dressler syndrome CTD- SLE ,RA, Dermatomyositis
- 9. Radiation therapy to chest Iatrogenic- pericardiocentesis, central line insertion, sternal biopsy, TV pacemaker lead implantation Uremia Anticoagulants Pneumopericardium Hypothyroidism Still disease Aortic Dissection
- 10. The signs and symptoms of cardiac tamponade all reflect a low cardiac output. Restlessness Agitation Drowsiness Stupor Decreased urine output Dyspnea Chest discomfort Syncope or near syncope Weakness Anorexia
- 11. Tachycardia Tachypnea Raised JVP Dimnished heart sounds Beck’s Triad Hypotension Hepatomegaly Pericardial friction rub
- 12. PULSUS PARADOXUS: It is an exaggeration >12mmHg or 9% of the normal inspiratory decrease in systemic blood pressure. It can be observed in patients with other conditions such as constrictive pericarditis, asthma, COPD, pulmonary embolism and right ventricular infarction with shock.
- 14. KUSSMAUL SIGN: It is paradoxical increase in jugular venous distention and pressure during inspiration. EWART SIGN/PINS SIGN: It is described as an area of dullnes with bronchial breath sounds and bronchophony below the angle of left scapula. Y DESCENT: It is abolished in jugular venous or right atrial wave form.It is due to increased intrapericardial pressure preventing diastolic filling of ventricles.
- 15. With a 12-lead ECG ,the following findings may be found: Sinus tachycardia Low-voltage QRS complexes Electrical alternans - an electrocardiographic phenomenon of alternation of QRS complex usually in a 2:1 ratio. It is caused by movement of heart in pericardial space. PR Segment depression
- 17. CHEST XRAY: may show cardiomegaly , water bottle shaped heart, pericardial calcification or evidence of chest wall trauma.
- 19. Compression of coronary sinus is observerd through CT scanning as an earlier marker for cardiac tamponade in 46% of patients.
- 21. Pericardial effusion Size often correlates w/risk of tamponade but not always. Diastolic chambers collapse RV diastolic collapse in early diastole (low sensitivity, high specificity) RA diastolic collapse in late diastole (very sensitive ,specificity 82% ).The longer the duration of diastolic collapse, the more specific it is for tamponade. LA collapse (present in ~ 25%, highly spec) Abnormal inspiratory increase of RV dimensions with abnormal inspiratory decrease of LV dimensions. IVC dilated & fails to collapse with inspiration at least 50%.
- 30. Definitive treatment of cardiac tamponade is achieved by removal of the pericardial fluid, thereby relieving the elevated intrapericardial pressure and improving hemodynamic status. • Oxygen • Bed rest with leg elevation - This may help increase venous return • Inotropic drugs (eg, dobutamine) - These can be useful because they increase cardiac output without increasing systemic vascular resistance • Volume expansion with blood, plasma, dextran, or isotonic sodium chloride solution, as necessary, to maintain adequate intravascular volume • Pericardiocentesis:Most require urgent and emergent pericardiocentesis.
- 31. › PERCUTANEOUS THERAPY: Pericardiocentesis allows the rapid drainage of pericardial fluid. Advantages are that it can be performed quickly, is less invasive than other drainage methods, and requires minimal preparation. Complications include laceration of the heart, coronary arteries, or lung Subxiphoid approach under echo guidance is most common - minimizes risk & can assess completeness of fluid removal. Apical Approach Can alternatively use Fluoroscopic guidance Pigtail catheter often left in place
- 32. › SURGICAL DRAINAGE (subxiphoid pericardiectomy, pericardial window, and subtotal pericardiectomy): May be best for loculated effusions, effusions containing clots or fibrinous material, and/or effusions that are borderline in size Allow creation of a pericardial window for recurrent effusions Surgical drainage is associated with more pain, a longer recovery time, and more periprocedural morbidity.
- 36. Possible Complications: Heart failure Pulmonary edema Shock Death
- 37. Cardiac tamponade is a medical emergency. If the fluid or blood is not quickly removed from the pericardium, death can occur quickly. The outcome is often good if the condition is treated promptly, but tamponade may come back.
- 38. Tension Pneumothorax Constrictive Pericarditis Cardiogenic Shock Pulmonary Embolism