questions 9

Cardiac Tamponade

Topic updated on 07/20/17 1:25pm

  • UltrasoundA 17-year-old male is stabbed in the left side of his chest just medial to the nipple. His blood pressure is 90/60 and his pulse is 130. On inspiration his JVP 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, but his CVP rises to 32.
  • Fluid collection in the pericardial sac that  restricts ventricular filling
    • leads to a decrease in cardiac output
    • symptoms and severity related to rate of fluid collection (not size of effusion)
  • Risk factors/causes include
    • pericarditis
    • malignancy
    • SLE   
    • tuberculosis
    • penetrating trauma 
      • most often medial to the left nipple
  • Cardiac tamponade should be considered in any patient who is
    • hemodynamically unstable
    • unresponsive to fluid resuscitation
  • Symptoms
    • severe chest pain
    • dyspnea
    • fatigue
    • anxiety
    • tachycardia
    • tachypnea
      • can rapidly lead to shock and death
  • Physical exam
    • Becks triad
      • hypotension
      • distant heart sounds
      • distended jugular veins
    • narrow pulse pressure
    • pulsus paradoxus
      • >10 mmHg drop in BP on inspiration
    • Kussmaul's sign 
      • elevated CVP on inspiration
  • EKG
    • electrical alterans is diagnositic  
      • beat-to-beat alternating of QRS magnitude
    • decreased amplitude
  • CXR  
    • may reveal enlarged, globular heart
  • Echocardiogram
    • shows RA/RV collapse in diastole
  • Severe MI, tension pneumothorax (absent breath sounds, hyperresonant percussion)
  • Nonoperative 
    • urgent pericardiocentesis & aggresive volume expansion
      • pericardiocentesis  
        • via subxyphoid method
        • critical for immediate relief of pericardial constriction
        • will produce aspirate of nonclotting blood
      • volume expansion
        • bolus IV fluids to boost cardiac output
  • Operative
    • surgical exploration
      • indications
        • perform following pericardiocentesis to identify the source of bleeding
    • balloon pericardiotomy and pericardial window
      • indications
        • may be warranted in cases of decompensation 
Prognosis, Prevention, and Complications
  • Prognosis
    • very poor without immediate intervention
  • Prevention
    • possible with early identification of high-risk patients
    • aided by proper post-traumatic screening
      • FAST ultrasound exam
    • necessitates careful following of vital signs
  • Complications
    • unidentified cardiac tamponade can rapidly lead to shock and death


Qbank (3 Questions)

(M2.CV.49) A 21-year-old male is brought to the local Level 1 Trauma Center by ambulance following an assault. Emergency medical services reports that he has been stabbed in the left chest wall. His temperature on arrival is 99.5°F (37.5°C), blood pressure is 80/35 mmHg, pulse is 100/min, respirations are 34/min, and oxygen saturation is 91% on high flow face mask oxygen. On exam, you note that the patient follows commands and is asking for his mother, his lungs are clear to auscultation, his heart sounds are muffled, and his neck veins are distended. FAST ultrasound is performed at the bedside. Of the following options, which is the next appropriate step in management? Topic Review Topic
FIGURES: A          

1. Transport the patient immediately to CT for imaging of the chest, abdomen, and pelvis
2. Initiate fluid resuscitation and perform chest compressions to maintain blood pressure
3. Initiate massive transfusion protocol
4. Take the patient to the operating room for evaluation and pericardial window
5. Perform immediate bedside thoracotomy to get proximal and distal control of the aorta

(M2.CV.53) A 21-year-old male is found down in an alley-way after police were called for concern of a drug deal taking place. The patient was conscious at the scene but had an obvious stab wound on his left chest, just medial to the nipple. In the ambulance on the way to the hospital, his blood pressure was found to be 88/66, heart rate of 132 bpm, and muffled heart sounds were noted on auscultation. What is the most likely treatment for this patient's condition? Topic Review Topic

1. Chest tube placement
2. Pericardiocentesis
3. Immediate needle decompression
4. Close the defect with sterile occlusive dressing and tape on three sides
5. NSAIDs and pericardiectomy

(M2.CV.154) A 59-year-old male is brought to the emergency room after sustaining thoracic trauma following an assault with a baseball bat. He reports shortness of breath. On physical examination, his vital signs are temperature of 37 C, heart rate 121 bpm, blood pressure 90/60 mmHg, respiratory rate 20 rpm, and oxygen saturation 99% on room air. Physical examination is significant for muffled heart sounds. You note his neck veins are distended. He does not respond to aggressive fluid resuscitation. Which of the following is classically true regarding the acute hemodynamic condition affecting this patient? Topic Review Topic

1. The patient should be started immediately on therapeutic heparin.
2. A finding of an increase in arterial pressure during inspiration > 10 mm Hg would be indicative of this condition.
3. Chest radiograph is the gold standard in diagnosis.
4. EKG may show electrical alternans.
5. Cardiac catheterization would show higher pulmonary capillary wedge pressure than right ventricular pressure during diastole.

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