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Snapshot
  • A 19-year-old man is stabbed in the left side of his chest. His blood pressure on presentation is 90/60 mmHg with a pulse of 130/min. On physical exam, he has muffled heart sounds and distended jugular veins. Upon inspiration, his blood pressure drops to 75/55 mmHg. His extremities are cool and clammy. He is immediately rushed to the operating room.
Introduction
  • Clinical definition
    • accumulation of fluid in the pericardial sac that restricts ventricular filling
  • Epidemiology
    • risk factors
      • pericarditis
      • malignancy
      • uremia
      • systemic lupus erythematosus
      • malignancy
      • tuberculosis
      • penetrating trauma
  • Etiology
    • pericardial effusion
    • hemorrhage into pericardial sac
    • iatrogenic
  • Pathoanatomy
    • pericardium
      • the pericardium is an elastic sac that can stretch to accommodate normal cardiac volume expansion
        • however, if stretched beyond normal physiological expansion, the pericardium will stiffen
  • Pathogenesis
    • cardiac tamponade
      • increased pericardial pressure from the fluid accumulation causes compression of the cardiac chambers
      • this results in decreased cardiac output and blood pressure
    • pulsus paradoxus
      • inhalation increases venous return → expands the right ventricle
        • in cardiac tamponade, the stiff pericardium will prevent the free wall from expanding
        • the only area for the right ventricle to expand is the interventricular septum, which will compress the left ventricle
        • compression of the left ventricle → decreased filling of the left heart → decreased blood pressure
  • Associated conditions
    • ruptured ascending aortic dissection
    • ventricular free wall rupture from myocardial infarction
  • Prognosis
    • in acute cases, cardiac tamponade can develop rapidly
    • in chronic cases, cardiac tamponade will develop gradually, as the pericardium can adjust slowly to the increased pressure over time
Presentation
  • Symptoms
    • chest pain
    • fatigability
    • often unresponsive to fluid resuscitation
  • Physical exam
    • Beck triad
      • muffled heart sounds
      • jugular venous distention  
      • hypotension
    • cardiac
      • ↑ heart rate
      • pericardial rub if the patient has an inflammatory pericarditis
    • pulsus paradoxus 
      • decrease of blood pressure > 10 mmHg during inhalation 
    • pulmonary
      • shortness of breath
      • lung fields are typically clear
    • extremities
      • cold and clammy
      • peripheral cyanosis
Imaging
  • Echocardiography
    • indications
      • for diagnosis of cardiac tamponade
      • most accurate test
      • for all patients
    • findings
      • diastolic collapse of the right heart
      • fluid in the pericardial space
      • swinging of the heart within the effusion
  • Radiography
    • indication
      • for all patients
    • views
      • chest
    • findings
      • enlarged cardiac silhouette seen only in subacute cardiac tamponade
      • in acute cases, pericardium will not accomodate build up of > 200 cc of fluid, which is required to appear enlarged on radiograph
Studies
  • Electrocardiogram (ECG)
    • indication
      • for all patients
    • findings
      • low voltage
      • electrical alternans
        • variations in the height of the QRS complex
        • from swinging of the heart in the chest
  • Right heart catheterization
    • indication
      • typically not performed as an initial test
    • finding
      • equilibration of pressures in all 4 chambers during diastole
  • Making the diagnosis
    • based on clinical presentation, ECG, echocardiogram, and chest radiography
Differential
  • Constrictive pericarditis
    • distinguishing factors
      • also has pulsus paradoxus, but also presents with
        • Kussmaul sign
          • increase (or absence of decline) in jugular venous pressure with inhalation
        • pericardial knock
  • Tension pneumothorax
    • distinguishing factors
      • decreased or absent breath sounds
      • hyperresonant percussion
Treatment
  • Management approach
    • all approaches focus on removal of the fluid in the pericardium
  • Conservative
    • close monitoring and volume expansion
      • indication
        • cardiac tamponade without hemodynamic compromise
        • modalities
          • serial echocardiographs
          • intravenous bolus of fluids
  • Procedural
    • percutaneous pericardiocentesis
      • indication
        • first-line treatment
  • Operative
    • surgical drainage
      • indications
        • patients with coagulopathy or need for biopsy
        • purulent pericarditis
        • traumatic cardiac tamponade
    • surgical drainage with pericardial window placement
      • indication
        • patients with chronic pericardial effusions
        • patients who decompensate
Complications
  • Death
 

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