1. Pericardial Tamponade
DRTEIMOURI H

2. Cardiac Tamponade 3 possible pericardial compression syndromes
accumulation of pericardial fluid under pressure and may be acute or subacute
Constrictive pericarditis
scarring and consequent loss of elasticity of the pericardial sac
Effusive-constrictive pericarditis
constrictive physiology with a coexisting pericardial effusion
Chicken or egg? Elevated wedge and Rt sided pressures s/p drainage

3. Cardiac Tamponade
Compression of all cardiac chambers due to increased pericardial pressure
Pericardium has some compliance with increased pressure, but once that is exceeded it begins to impair diastolic compliance, reducing cardiac filling
Much of the pressure is transmitted to the Rt Vent/Atrium (lower pressure systems) which causes which causes bulging of interventricular septum and decreased Lt ventricular compliance and filling

4. Pericardial Effusion Pericardium typically has 20-50 ml of fluid
Acuity of fluid accumulation plays a large role in pericardial compliance
Rapid accumulation (trauma) gives pericardium no time to adjust, therefore a small amount of fluid can cause tamponade
Slow accumulation allows pericardial compliance to increase allowing a larger volume of fluid into sac
However, when pericardial pressures > Rt ventricular pressure tamponade physiology can occur

5. Causes of Pericardial Tamponade
Malignancy
HIV infection
Infection - Viral, bacterial (tuberculosis), fungal
Drugs - Hydralazine, procainamide, isoniazid, minoxidil
Postcoronary intervention (ie, coronary dissection and perforation)
Trauma
Cardiovascular surgery (postoperative pericarditis)
Postmyocardial infarction (free wall ventricular rupture, Dressler syndrome)
Connective tissue diseases - Systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis
Radiation therapy
Iatrogenic - After sternal biopsy, transvenous pacemaker lead implantation, pericardiocentesis, or central line insertion
Uremia
Idiopathic pericarditis
Complication of surgery at the esophagogastric junction such as antireflux surgery
Pneumopericardium (due to mechanical ventilation or gastropericardial fistula)

6. Symptoms Dyspnea, tachycardia, tachypnea Cold, clammy extremities
Malignancy – weight loss, fatigue, anorexia
Chest pain – pericarditis, MI
Joint pain – connective tissue
Renal failure – uremia
Medications – drug related lupus
Recent procedure – pacemaker, central line
TB – night sweats, fever
Radiation – cancer history

7. Physical Exam Findings
Beck’s Triad – JVD, hypotension, diminished heart sounds
Hepatomegaly
Evidence of chest wall trauma
Pulsus paradoxsus > 12 mm Hg
Kussmaul sign - paradoxical increase in venous distention and pressure during inspiration
Abolished y descent

8. Diagnosis
EKG – low voltage, sinus tach, PR depression, electrical alternans

9. Diagnosis
CXR
enlarge cardiac silhouette, water bottle shaped heart

10. Diagnosis Echocardiogram (tamponade is clinical diagnosis)
Pericardial effusion
Early diastolic collapse of the right ventricular free wall
Late diastolic compression/collapse of the right atrium
Swinging of the heart in its sac
LV pseudohypertrophy

12. Diagnosis Rt Heart Catheterization
If patient is stable and diagnosis is in doubt can perform a Rt heart catheterization to measure Rt sided pressures
In tamponade, near equalization (within 5 mm Hg) of the right atrial, right ventricular diastolic, pulmonary arterial diastolic, and pulmonary capillary wedge pressure
Rt atrial pressure tracings show abolished systolic y descent

13. Treatment What to do while your waiting on CT Surgery… Oxygen
Volume expansion with blood, plasma, or saline to maintain adequate intravascular volume
Bed rest with leg elevation
This may help increase venous return.
Inotropic drugs (i.e. dobutamine)
Choose inotropes that do not increase systemic vascular resistance while increasing cardiac output.

14. Treatment Once CT Surgery or Cardiology arrives Recurrent effusion
Pericardiocentesis
can be fluoroscopically or TTE guided
Pericardial window
involves the surgical opening of a communication between the pericardial space and the intrapleural space
Recurrent effusion
Pericardectomy
Pericardial-peritoneal shunt
Pericardiodesis - corticosteroids, tetracycline, or antineoplastic drugs can be instilled into the pericardial space sclerosing the pericardium

15. Treatment No one shows up and cardiac arrest is called
Emergency subxiphoid percutaneous drainage
A 16- or 18-gauge needle is inserted
at an angle of 30-45° to the skin,
near the left xiphocostal angle,
aiming towards the left shoulder
When performed emergently, this
procedure is associated with a
reported mortality rate of approximately
4% and a complication rate of 17%

16. References
Spodick, DH. Acute cardiac tamponade. N Engl J Med 2003; 349:684.
Chou, TC. Electrocardiography in Clinical Practice: Adults and Pediatrics, 4th ed, WB Saunders, Philadelphia 1996
Reydel, B, Spodick, DH. Frequency and significance of chamber collapses during cardiac tamponade. Am Heart J 1990; 119:1160
Troughton, RW, Asher, CR, Klein, AL. Pericarditis. Lancet 2004; 363:717.
Reddy, PS, Curtiss, EI, O'Toole, JD, Shaver, JA. Cardiac tamponade: hemodynamic observations in man. Circulation 1978; 58:265.
Bruch, C, Schmermund, A, Dagres, N, et al. Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment. J Am Coll Cardiol 2001; 38:219.
Gillam, LD, Guyer, DE, Gibson, TC, et al. Hydrodynamic compression of the right atrium: A new echocardiographic sign of cardiac tamponade. Circulation 1983; 68:294.
Fitchett, DH, Sniderman, AD. Inspiratory reduction in left heart filling as a mechanism of pulsus paradoxus in cardiac tamponade. Can J Cardiol 1990; 6:348