Cardiac Tamponade - Prof Yogiarto, MD, FIHA.pdf

8/18/2019 Cardiac Tamponade - Prof Yogiarto, MD, FIHA.pdf

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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015

R. MOHAMMAD YOGIARTO

CARDIAC TAMPONADE


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INTRODUCTION

Claudius Galen (131-201 AD)

Richard Lower (1669)

Edmund Rose


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Introduction…

Cardiac tamponade is defined as an accumulationof fluid in the pericardial sac, creating an increasedpressure within the pericardial space that impairsthe ability of the heart to fill and to pump.

Decrease in stroke volume, cardiac output andsystemic perfusion leading to life-threatening organ

dysfunction.

Understanding the physiological changes producedby tamponade is essential to diagnosis andtreatment.

(Tsang et.al,1999;Ramos and Lily,2007; Winter,2012)


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EPIDEMIOLOGY


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ETIOLOGY

Malignancies

Septicaemia

Renal failure

pericarditis uremia

Drugs

Cyclosporine

Anticoagulants

Thrombolytics

(Tsang et.al,1999;Ramos and Lily,2007; Winter,2012)

Injury

Recent cardiac surgery

Indwellinginstrumentation

Blunt chest trauma Ventricle free wall rupture

Desection of Aneurismaaorta

Connective tissue disease


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PATOPHYSIOLOGY

Cardiac tamponade develops as a result of fluidaccumulation within the pericardial space

Increased intrapericardial pressure, progressivelimitation of ventricular diastolic filling, reduction of stroke volume and cardiac output

(Ramos and Lily, 2007; Sauleda J.S et al,2008; Le Winter et al,2012)


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IMPAIRED DIASTOLIC FILLING OF VENTRICLES

PERICARDIAL FLUID UNDER PRESSURE

CARDIAC TAMPONADE

PULMONARY

RALES

SYSTEMIC

VENOUS

CONGESTION

PULMONARY

VENOUS

CONGESTION

JUGULAR VENOUS

DISTENTION,

HEPATOMEGALY,

ASCITES, PERIPHERAL

EDEMA

ELEVATED VENOUSPRESSURES IMPAIRED STROKEVOLUME

DECREASED

CARDIAC OUTPUT

HYPOTENSION

REFLEX

TACHYCARDIA


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Types of tamponade

Acute tamponade

- Due to trauma, rupture of the heart or aorta or complication of aninvasive diagnostic or therapeutic intervention

- Sudden in onset

- Hypotension common

Subacute tamponade

- Pericardial fluid accumulates slowly

- Hypotension with a narrow pulse pressure, reflecting limited strokevolume. However, patients with preexisting hypertension may remainhypertensive due to increased sympathetic activity

( Spodick D.H, 2003)


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Types of tamponade….

Low pressure tamponade Severely hypovolemic (hemorrhage, hemodyalisis, or

overdiuresis)

intracardiac and pericardial diastolic pressures are only 6 to12 mmHg

fluid challenge usually elicits typical tamponade

hemodynamics

Regional tamponade

caused by a loculated, eccentric effusion

typical physical, hemodynamic, and echocardiographicsigns of tamponade may be absent

(Sauleda J.S et al.2008; Sauleda J.S et al.2006


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Physical Examination Findings

Hypotension with pulsus paradoxus ( decreased systolicblood pressure > 10 mmHg during inspiration whereasdiastolic blood pressure remains unchange )

Muffled heart sounds : suppressed heart sounds occur due to the muffling effects of the fluid surrounding the

heart

Elevated JVP


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Tachycardia

Pericardial friction rub: can be found in patient cardiactamponade due to pericarditis , characterized by scratchy andgrating sound tends to be louder during inspiration with thepatient leaning forward. Best heard in left lower sternal border

Tachipneu


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ELECTROCARDIOGRAM

Electricals alternans


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ELECTROCARDIOGRAM….

Common Findings

Sinus tachycardia

Non-specific ST segment and T wave changes

Changes associated with acute pericarditis (includediffuse ST Elevation & PR depression)

Other Findings Low voltage

Electrical alternans :beat to beat alterations in the QRScomplex swinging of the heart

Best seen in leads V2 to V4

Combined P wave and QRS complex alternation(specific for cardiac tamponade)

(Le Winter M.M, 2012)


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CHEST X-RAY FINDINGS

Enlarge cardiacsilhouet “ erlenmeyer

shape” with clear

lungs

Normal chest X-ray

Cardiomegaly


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ECHOCARDIOGRAPHY

2D and M-mode• RV diastolic collapse• RA collapse• Inferior Vena Cava (IVC)

plethora, dilatation and < 50 %reduction in the diameters of IVC during inspiration

• LA and very rarely LV collapse• Increased LV diastolic wall

thickness “pseudohypertrophy”

• “SWINGING HEART”

• Doppler study discloses marked

respiratory variation intransvalvular flow

(Tsang et al,1999, Spodick D.H, 2003;Feigenbaum et al,2006; Pande A.V, 2007;

Bulwer B.E, 2009)


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ECHOCARDIOGRAPHY

Confirm size of the pericardial effusion Small defined as < 10 mm in echo-free space in diastole

Moderate defined as 10-20 mm ( at least >= 10 mmposteriorly)

Large defined as >= 20 mm

Very large >= 20 mm and compression of the heart

Confirm location of the pericardial effusion

Rule out loculated effusions

Assist pericardiocentesis


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Ct scan

Focal atele

Large

EffusionCollapsed RV

Collapsed RV

a large pericardial

effusion


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DIAGNOSIS

Tamponade is a Clinical

Diagnosis

TRIAS BECK :

Hypotension with Pulsus

paradoxus

Elevated JVP

Muffled heart sounds

Other detection methods

:

EKG

CXR

Trans Thoracal

Echocardiography

CT, MRI

( Ramos Y and Lily L.S,2007; Le Winter et al.,2012; Hoit B.D, 2015)


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DIFFERENTIAL DIAGNOSIS

• Primary myocardial dysfunction meansthe heart is unable to produce anadequate cardiac output.

Cardiogenicshock

• Characteristic mill-wheel murmur, asplashing auscultatory sound due to thepresence of gas in the cardiac chambers

• this condition can be seen after penetrating

chest wall injury, rupture esophagus andbronchopericardial fistula

Pneumothorax


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DIFFERENTIAL DIAGNOSIS

• Caused by thickened pericardium impairingventricular diastolic fx. May mimic tamponade inthe absence of an effusion.

• In constrictive pericarditis miocardium is notcompresed until the the heart expanses to fill

pericardium during mid to late diastolic• Kusmaull sign- a paradoxical rise in JVP oninspiration in but not found in cardiac tamponade

Constrictivepericarditis

• Can cause shortness of breath ,hypotension, elevated JVP BUT NOT

pulsus paradoxus•

Pulmonary

embolism


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Management

European Society of Cardiology in Guidelines on theDiagnosis & Management of Pericardial Diseases-2004 :

Class 1:

Cardiac tamponade

Effusion > 20 mm in echocardiography ( diastole )

Suspected purulent or tuberculous pericardial effusion

Class II a:

Effusion 10-20 mm in echocardiography in diastole for diagnostic purposes other than purulent pericarditis or

tuberculosis ( pericardial fluid and tissue analyses,pericardioscopy, and epicardial / pericardial biopsy)

Suspected neoplastic pericardialeffusion


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Management………..

Class II b Effusions < 10 mm in echocardiography in

diastole for diagnostic purpose other thanpurulent, neoplastic or tuberculous pericarditis

Contraindications ( Class III )

Aortic disection

Relative contraindications include uncorrectedcoagulopathy, anticoagulant therapy,thrombocytopenia < 50.000/ mm3, small ,

posterior, and loculated effusions.


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Management….

IVF especialy if hypovolemia

Temporary inotropic support

Serial echo after draining fluid Analysis of pericardial fluid :

Specific gravity, PH, glucosa, LDH, protein, cellcount.cytology.

Staining and diagnosis for bacteria, fungi , TB

( Ramos Y and Lily,2007; Gumrukcougiu et al, 2011; Hoit BD ,2015)


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Evidence of cardiac tamponade


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Score ≥ 6 Score ≤ 6


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Pericardiocentesis

Guided by echocardiography or fluoroscopy

Bedside, ICU, Cardiac cath.labor operating room

Intercostal artery should beavoided

Subxiphoid approach ( longneedle directed towards the left

shoulder at a 30°

angle to theskin(ESC Guidelines on the Diagnosis &

Management of Pericardial Diseases-

2004


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Pericardiocentesis….

Stop the needle as soon as the effusion isaspirated

Exchange for soft J-tip guidewire and after dilatation for multi-holed pigtail catheter

Drain fluid in < 1 L steps to avoid the acute RVdilatation

Perform prolonge pericardial drainage until < 25 ml/day

(ESC Guidelines on the Diagnosis & Management of Pericardial Diseases- 2004)


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Surgical drainage

Indications for urgent surgical treatment of cardiactamponade include:

hemopericardium due to type A aortic dissection

ventricular free wall rupture in acute myocardialinfarction

trauma, or purulent effusion in unstable septicpatients

loculated effusions that can not be managedpercutaneously.

(ESC Guidelines on the Diagnosis & Management of Pericardial Diseases 2004)


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Summary

Cardiac tamponade is a life-threatening emergency and animportant cause of obstructive shock.

Tamponade can occur as a complication of a number of medical

conditions, as well as in trauma or cardiac surgery patients.

Prompt echocardiographic confirmation of tamponade should be

performed when the diagnosis is suspected.

Echocardiographic signs of right-sided diastolic chamber collapse

and ventricular interdependence are highly suggestive of cardiac

tamponade.

Treatment involves careful fluid resuscitation and inotropes,butthis is not a substitute for definitive drainage via either

percutaneous or open surgical techniques.


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Hypotension with pulsus paradoxus ( decreased systolicblood pressure > 10 mmHg during inspiration whereasdiastolic blood pressure remains unchange )

Muffled heart sounds : suppressed heart sounds occur due to the muffling effects of the fluid surrounding the

heart

Elevated JVP


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Tachycardia

Pericardial friction rub: can be found in patient cardiactamponade due to pericarditis , characterized by scratchy andgrating sound tends to be louder during inspiration with thepatient leaning forward. Best heard in left lower sternal border

Tachipneu

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Cardiac Tamponade - Prof Yogiarto, MD, FIHA.pdf