questions 4

Cardiac Tamponade

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Topic updated on 09/20/17 11:18pm

Snapshot
  • A 17-year-old male is stabbed in the left side of his chest just medial to hid nipple. His blood pressure is 90/60 mm Hg with a HR of 130/min. On inspiration his jugular venous pressure increases and his peripheral pulses and blood pressure decrease. Breath sounds and CXR are unremarkable. After 2L of isotonic saline, his blood pressure remains low, whereas his CVP rises to 32.
Introduction
  • Fluid in the pericardial sac restricts filling of all cardiac chambers
  • Symptoms and severity related to rate of fluid collection
  • Risk factors 
    • known pericarditis
    • trauma (penetrating trauma medial to the left nipple)
Presentation
  • Findings
    • severe chest pain
    • tachycardia
    • tachypnea that can rapidly lead to death
  • Becks triad
    • hypotension
    • distant ("muffled") heart sounds
    • distended jugular veins
  • Other physical findings
    • distant narrow pulse pressure
    • tachypnea
    • pulsus paradoxus  
      • result of interdependence of the ventricles such that an increased filling of the right heart during inspiration results in simultaneous decreased filling of the left heart  
      • results in drop in systolic BP of more than 10 mmHg with inspiration 
      • upon exam, one may auscultate beats during inspiration, but will be unable to palpate them at the radial artery
    • Kussmaul's sign 
      • elevated CVP on inspiration
Evaluation
  • Imaging
    • CXR may reveal enlarged globular heart
    • Obtain immediate echocardiogram if time permits 
Treatment
  • Urgent pericardiocentesis via subxyphoid method
  • Definitive treatment in cases of penetrating trauma to the heart will require surgical intervention


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Qbank (3 Questions)

TAG
(M1.CV.75) A 45-year-old male presents to the emergency department following a 5-car motor vehicle collision requiring mechanical extraction. On arrival to the ED, his airway is patent with normal breathing. His pulse is 110/min, blood pressure is 85/40 mmHg, respirations are 22/min, and oxygen saturation of 98% on room air. He is in clear distress and has the findings shown in Figure A. A chest radiograph and ultrasound examination are performed, which are shown in Figures B and C respectively. It is noted that his systolic BP decreases by 15 mmHg whenever he inspires. Which of the following diseases can exhibit a similar manifestation? Topic Review Topic
FIGURES: A   B   C      

1. Pleural effusion
2. Rib fracture
3. Tension pneumothorax
4. Aortic dissection
5. Congestive heart failure

PREFERRED RESPONSE ▶
TAG
(M1.CV.114) A 27-year-old male arrives in the emergency department with a stab wound over the precordial chest wall. The patient is in distress and is cold, sweaty, and pale. Initial physical examination is significant for muffled heart sounds, distended neck veins, and a 3 cm stab wound near the left sternal border. Breath sounds are present bilaterally without evidence of tracheal deviation. Which of the following additional findings would be expected on further evaluation? Topic Review Topic

1. Decrease in the patient's heart rate by 15 beats per minute with inspiration
2. Elevated blood pressure to 170/110
3. Steadily decreasing heart rate to 60 beats per minute
4. 15 mmHg decrease in systolic blood pressure with inspiration
5. Decrease in central venous pressure by 5 mmHg with inspiration

PREFERRED RESPONSE ▶
TAG
(M1.CV.148) A 34-year-old patient is brought to the emergency room after a motor vehicle accident. An EKG shows sinus tachycardia and chest radiograph reveals an enlarged cardiac silhouette. While observing sinus tachycardia on the patient's telemetry, you note that the radial pulse cannot be palpated during inspiration. What should be the next step in management of this patient? Topic Review Topic

1. IV Heparin
2. Pericardiocentesis
3. Chest CT scan
4. Pericardial window
5. Insert chest tube

PREFERRED RESPONSE ▶
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