Medical Minute: Cardiac Tamponade

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July 21, 2015 by dailybolusoflr

By: Michael Ehmann, MD MPH MS


Figure <!–[if supportFields]> SEQ Figure \* ARABIC <![endif]–>1<!–[if supportFields]><![endif]–>: Apical view (http://www.cardiovascularultrasound. com/content/figures/1476-7120-8-27-1.jpg)

Figure <!–[if supportFields]> SEQ Figure \* ARABIC <![endif]–>2<!–[if supportFields]><![endif]–>: Subxiphoid view (http://www.sonoguide.com/Cardiac_Figure17.html)


I.                Background
a.      Intrapericardial pressure > RVEDP
b.     Rapid accumulation of pericardial fluid increases risk of tamponade
                                                    i.     Acute 50-100mL
                                                  ii.     Chronic >1000mL
c.      Risk factors
                                                    i.     Thoracic trauma
                                                  ii.     Post-cardiac procedure
                                                iii.     Neoplasm
                                                iv.     Aortic dissection
                                                  v.     ESRD
                                                vi.     Pericarditis
                                              vii.     Hypovolemia
II.             Symptoms
a.      Dyspnea
b.     Syncope
III.           Exam
a.      Tachycardia, narrow pulse pressure 
b.     Beck’s Triad
                                                    i.     Distended neck veins, muffled heart sounds, hypotension
c.      Pulsus paradoxus
                                                    i.     >10mmHg drop in SBP during supine inspiration
d.     CXR: cardiomegaly, epicardial fat pad
e.      EKG: tachycardia, low voltage, electrical alternans
IV.           Treatment
a.      IVF, pericardiocentesis, pericardiectomy
V.              Point of care echocardiogram
a.      Pericardial effusion plus any one of following:
                                                    i.     RA systolic collapse in subcostal or apical view
1.     Most sensitive (earliest sign)
                                                  ii.     RV diastolic collapse in subcostal or PSL view
1.     Easiest to visualize in PSL
                                                iii.     Absent IVF respiratory variation
1.     Inspiratory collapse >50% is 97% sensitive to rule out tamponade
                                                iv.     TV/MV inflow peak to peak variation in apical view

1.     Normal variation <25% (TV) and <15% (MV) with respiration
Figure <!–[if supportFields]> SEQ Figure \* ARABIC <![endif]–>3<!–[if supportFields]><![endif]–>: TV inflow variation (Dawson, Mallin 2013)
References

  1. Himelman RB, et al. J Am Coll Cardiol 1988;12:1470–7.
  2. Niemann JT. Ch 59. The cardiomyopathies, myocarditis and pericardial disease. In: Tintinalli JE, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw Hill; 2011.
  3. Reardon RF, et al. Ch 6. Cardiac. In: Ma O, et al., eds. Ma and Mateer’s Emergency Ultrasound. 3rd ed. New York: McGraw Hill; 2014.
  4. Dawson M, Mallin M. “Pericardial Effusion and Tamponade.” Video blog post. Pericardial Tamponade. Learn This. Know This. Ultrasound Podcast, Nov. 2013. Web.

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