1. CPC #4 Edward K. Kasper, M.D. Chief of Clinical Cardiology Johns Hopkins Hospital

2. A 60 –year-old female u Multiple risk factors for coronary artery disease on dialysis u Presents with hypoglycemia u Elevated troponin – ASA, heparin, BB, TNG u Probable UTI - gatifloxacin u Large pericardial effusion u Asystolic cardiac arrest and dies

3. Timeline of Events u 12/10 – ED, hyperkalemia, Hct 44%, started on gatifloxacin u 12/11 – Medicine, BB, ASA, Heparin, nitrates, dialyzed, Hct 35% u 12/12 – Dialysis, echo - large pericardial effusion, no tamponade u 12/13 – Water bottle heart on CXR, asystolic at 5 AM

4. JAMA April 25, 2007

5. Causes of Pericardial Effusion u Idiopathic u Infection (bacterial, viral, retroviral, fungal, parasitic, TB) u Trauma u Hemorrhage* (trauma, MI, Aortic rupture, heart surgery) u Cancer u Radiation therapy u Kidney failure u Autoimmune disorders (SLE, RA) u Hypothyroidism u Drugs (PCN, anticoagulants*)

6. TamponadeTamponade 3 10 20 X Normal Tamponade

7. Tamponade - Clinical Findings u They look sick! u Tachypnea u Pale u Diaphoresis u Cool extremities u Cyanosis u Confusion u Hypotension u Paradoxical pulse u Elevated JVP u Tachycardia

8. Cardiac Arrest u CAD* u Cardiomyopathy u Myocarditis u Commotio cortis u Tamponade* u Embolism u Pneumothorax u Hypovolemia u Hypoxia u Potassium (high, low) u Calcium (high) u Catecholamines u Hypothermia u Long QT u Electrocution u Drowning

9. Drug-Induced Long QT Syndrome u Possible – gatifloxacin u www.arizonacert.org

10. Possible Hypotheses u Silent myocardial infarction leading to cardiac rupture into pericardial space u Aortic rupture into pericardial space u Pericarditis (uremic) with heparin-induced bleeding into pericardium u Primary arrhythmic event

11. Correct Me If I’m Wrong!