Cardiac Tamponade

Andrew S. Liteplo, MD, RDMS, FACEPEmergency Ultrasound Fellowship Director

Department of Emergency MedicineMassachusetts General Hospital

Echo Florida: Contemporary EchocardiographyAmerican Society of Echocardiography

Sat. Oct 12, 2013. 1015-1045 am

Focused Cardiac Ultrasound

• What? Echo done at point-of-care by treating clinician

• Who? Anyone who needs real-time assessment of certain cardiac parameters

• Why? Improve decision-making, optimize treatment

• Scope of practice? Focused questions of 1) ejection fraction, 2) pericardial effusion, 3) RV dilatation

Pericardial effusion

• Pericardial space usually has only a small amount of fluid

• Effusion when fluid accumulates in this space--trauma, uremia, metastases, aortic dissection, rheumatologic

• Tamponade when the intrapericardial pressures equal cardiac pressures

• Sx: SOB, CP, hypotension, syncope

FCU for pericardial effusion

• One of the easier questions to answer

• High degree of sensitivity and specificity of FCU in medical and trauma patients

• Found in up to 14% of undifferentiated dyspneic patients

4 views that we teach

How to identify effusion

• Anechoic stripe adjacent to pericardium

• Should not be only anterior

• Extends above descending aorta

Pericardial effusion

Sizing pericardial effusions

Pitfalls

• Fat pad

• Pleural effusions

• Clotted blood

• Loculated effusions

Effusion vs Tamponade

• Intrapericardial pressures rise

• When equal RA and RV, chambers begin to collapse

• Hemodynamic compromise

Effusion vs Tamponade

Effusion vs Tamponade

Diagnosing Tamponade

Diagnosing Tamponade

• FCU may be used to identify

• Delayed RV diastolic expansion

• RA or RV diastolic collapse

• Comprehensive echo

• Additional two-dimensional and Doppler findings that can confirm or refute the degree of suspected hemodynamic compromise and provide a means of serially monitoring its progress

Tamponade

Diagnosing Tamponade• Advanced methods of detecting tamponade

exist

• Note: this is ADVANCED and outside the scope of point-of-care echo

Clinical vs Echo Tamponade

VS Echo

Pericardial effusion

StableFully expanding

RA/RV

Impending Tamponade

Stable Collapsing RA/RV

TamponadeTachycardiaHypotension

Collapsing RA/RV

Clinical vs Echo Tamponade

VS Echo Action

No effusion StableFully expanding

RA/RVRuled out.

None.

Pericardial effusion

StableFully expanding

RA/RVUrgent eval.

Impending Tamponade

Stable Collapsing RA/RVIVF.

Consult.

TamponadeTachycardiaHypotension

Collapsing RA/RVIVF. Drain.

STAT consult.

T. Tsang, M. Enriquez-Sarano, W. Freeman, M.E. Barnes, L.J. Sinak and B.J. Gersh et al., Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years, Mayo Clin Proc 77 (2002), pp. 429–436

Silvestry FE, Kerber RE, Brook MM, Carroll JD, Eberman KM, Goldstein SA, Herrmann HC, Homma S, Mehran R, Packer DL, Parisi AF, Pulerwitz T, Seward JB, Tsang TS, Wood MA. Echocardiography-guided interventions. J Am Soc Echocardiogr. 2009 Mar;22(3):213-31; quiz 316-7.

Pericardiocentesis

• Echo-guided>>blind

• Anterior chest wall, aim for biggest pockets

• Avoid intercostal NV bundle

• Once youʼre in, advance catheter, withdraw needle

• Agitated saline

Summary

• Main benefit of point-of-care cardiac ultrasound is in ruling out tamponade by showing no effusion.

• Can also easily identify unsuspected effusion

• Effusion + suspected tamponade = comprehensive echo, IVF, and drainage

Questions?