cardiac tamponade

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PERICARDIAL EFFUSION & CARDIAC TAMPONADE:

PERICARDIAL EFFUSION & CARDIAC TAMPONADE by DR. AVINASH PRAKASH

IMPORTANT POINTS :

IMPORTANT POINTS Definition Patho -physiology etiology Clinical features Investigations Treatment

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DEFINITION “ clinical syndrome caused by accumulation of fluid in the pericardial space , resulting in reduced ventricular filling and subsequent hemodynamic compromise ” “ an abnormal accumulation of fluid in the pericardial cavity ” PERICARDIAL EFFUSION CARDIAC TAMPONADE

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How much pericardial fluid is needed to impair diastolic filling ? PATHO-PHYSIOLOGY

Pericardial Pressure-Volume Relation :

Pericardial Pressure-Volume Relation

ETIOLOGY:  blood/ pus/serous:

ETIOLOGY: blood/ pus/serous hypothyroidism physical trauma Pericarditis ( bact /TB/HIV) myocardial rupture after heart surgery a ortic dissection neoplastic

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CLINICAL SYMPTOMS Breathlessness Chest pain, Abdominal pain, Fatigue , Fever , Cough , Palpitation, Maybe in shock

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PHYSICAL EXAMINATION tachycardia , distant or muffled heart sounds jugular vein distension falling BP, paradoxical pulse (a drop in inspiratory BP by greater than 10 mmHg).

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Beck's triad .( rapid accumulation of pericardial fluid) Hypotension occurs because of decreased stroke volume jugular-venous distension due to impaired venous return to the heart m uffled heart sounds due to fluid inside the pericardium

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complete blood count (CBC) RFT,LFT PT,INR CKMB, TROP-T ANA assay , ESR Rh FACTOR HIV testing Mantoux test Pericardial fluid C/S, AFB INVESTIGATIONS

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ECG sinus tachy ,low voltage QRS complexes , electrical alterans ,

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CXR : large , globular heart, enlarge cardiac silhouette, water bottle shaped heart

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ECHO: “ diagnostic test of choice “

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MEDICINE NSAIDS/Aspirin : for most pericarditis Colchicine: COPE trial Systemic steroids: causes recurrence ; only if unresp to NSAIDS Hemodynamic support : IVF, Inotropes Pus? – drain+ i.v. antibacterial therapy TB- ATT+ iv predni 1-2 mg/kg x 7 d Antineoplastic therapy TREATMENT: PERICARDIAL EFFUSION SURGERY (if S/S persist) Pericardial sclerosis (tetra , doxy ,cisplatin,5 –FU) Sub-xiphoid pericardial window with pericardiostomy Thoracotomy: pleuro -pericardial window Video-assisted thoracic surgery The mortality and morbidity of pericardial effusion is dependent upon etiology and comorbid conditions

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TREATMENT: PERICARDIAL EFFUSION

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No role for elective pericardiocentesis in asymptomatic , unless for diagnosis or if pus / TB TREATMENT: PERICARDIAL EFFUSION

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Remove as much as possible Large effusion x 3 months TREATMENT: PERICARDIAL EFFUSION

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TREATMENT: CARDIAC TAMPONADE Cardiac tamponade is a medical emergency Untreated, cardiac tamponade is rapidly and universally fatal Prompt diagnosis and treatment is the key . O2 Volume expansion Bed rest Inotropic drugs Positive-pressure mechanical ventilation should be avoided Pericardiocentesis : A Swan- Ganz catheter can be left in place for continuous monitoring of hemodynamics repeat ECHO and a repeat CXR within 24 hours .

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PERICARDIOCENTESIS Equipment Bed side ECHO ECG 18 gauge spinal needle 3 way 20 cc syringe A wire with alligator clips

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PREPARATION: surface landmarks Clean Drape LA Raise the head of the bed PERICARDIOCENTESIS

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APPROACH Sub-xiphoid : Echo guided ECG guided Blind Para-sternal PERICARDIOCENTESIS

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AFTER CARE Monitor vitals Look out for complications Repeat ECHO & CXR If Pt still symptomatic then may require placement of catheter in the pericardial space or surgical creation of a pericardial window PERICARDIOCENTESIS

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COMPLICATIONS Cardiac arrhythmia Pneumothorax Pleural effusion Myocardial injury Peritoneal injury Liver/stomach injury Internal mammary artery injury Diaphragmatic injury PERICARDIOCENTESIS

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RECURRENT TAMPONADE pericardial window Sclerosing the pericardium Pericardio -peritoneal shunt Pericardiectomy

TAKE HOME MESSAGE:

Signs & symptoms and management of pericardial effusion depends on the rate of accumulation of effusion Elective pericardiocentesis is not warranted in all pericardial effusions Cardiac tamponade is a medical emergency, and if untreated , its rapidly and universally fatal Prompt diagnosis and treatment is the key . Pericardiocentesis is a life saving procedure in tamponade Monitor vitals after the procedure to look for complications TAKE HOME MESSAGE

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