Ver el código de «Pericardial effusion and tamponade»

==Background==
[[File:Body Cavities Frontal view labeled 2.jpg|thumb|(d) Pericardial cavity, part of the inferior mediastinum, in relation to (a) superior mediastinum; (c) pleural cavities; and (e) diaphragm.]]
[[File:2004 Heart Wall.jpg|thumb|Anatomy of the pericardium.]]
[[File:PMC3518705 kcj-42-725-g005.png|thumb|Pericardial pressure-volume relationships in patients who have rapidly (left curve) and gradually (right curve) developed a pericardial effusion. In rapid accumulating effusion (left curve), even a small effusion volume can exceed the limit of parietal pericardial stretch and finally causes a steep rise in pressure. In contrast, slow accumulating effusion (right curve) requires a long time and a large volume to exceed the limit of pericardial stretch because of the activating compensatory mechanisms.]]
*Always consider in patient with [[PEA]]
*Always consider in patient with penetrating trauma anywhere in the cardiac box (80% result in tamponade)
**[[Gun shot wounds]] are less likely to result in tamponade because pericardial defect is larger
**Right ventricle is the most commonly injured chamber of the heart due to its anatomic location<ref>Gunay C, et al. Surgical challenges for urgent approach in penetrating heart injuries. Heart Surg Forum. 2007;10(6):E473-E477. doi:10.1532/HSF98.20071098</ref>
*Pathophysiology
**Increased pericardial pressure > decreased RV filling > decreased cardiac output

===Etiology===
*Hemopericardium
**Trauma
**Iatrogenic (misplaced [[central line]])
**[[Coagulopathy|Bleeding diathesis]]
**[[Myocardial rupture|Ventricular rupture]] (post-[[MI]])
*Non-hemopericardium
**Cancer - most commonly lung, breast, prostate, or hematologic
***[[Melanoma]] has predilection for heart
***May be related to radiation, infection, chemotherapy
**[[Pericarditis]]
***Infectious
***Uremic ([[renal failure]])
**[[HIV]] complications (infection, [[Kaposi sarcoma]], [[lymphoma]])
**[[SLE]] and other autoimmune or [[connective tissue disorder]]s
**Post-radiation
**[[Myxedema]]

==Clinical Features==
*[[Chest pain]], shortness of breath, cough, fatigue
*[[CHF]]-type appearance
*Tachycardia
*Narrow pulse pressure
*Friction rub
*Pulsus paradoxus (dec in BP on inspiration)
*Beck's Triad (33% of patients)
**[[Hypotension]]
**Muffled heart sounds
**JVD

==Differential Diagnosis==
{{Template:Chest Pain DDX}}

==Evaluation==
===[[Pulsus Paradoxus]]===
*>10mmHg change in systolic BP on inspiration

===[[CXR]]===
[[File:Massivepericarialeffusion.png|thumb|Massive pericardial effusion on chest x-ray]]
*Enlarged cardiac silhouette

===[[ECG]]===
[[File:Pericardial effusion with tamponade.png|thumb|Sinus tachycardia with low QRS voltage and electrical alternans]]
*Often normal
*[[Tachycardia]] (bradycardia is ominous finding)
*Electrical alternans
*Low voltage
**All limb lead QRS amplitudes <5 mm or I+II+III<15;<ref>Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.</ref>
**'''OR''' All precordial QRS amplitudes <10 mm or V1+V2+V3<30

===[[Cardiac ultrasound|Ultrasound]]===
[[File:Pericardial effusion with tamponade (cropped).gif|thumb|Transthoracic echo of pericardial effusion showing "swinging heart"]]
[[File:PericardialeffusionUS.png|thumb|Pericardial effusion on ultrasound]]
[[File:RV_Collapse_M_mode.JPG|thumbnail|Collapse M mode]]
[[File:MV_inflow_variation.JPG|thumbnail|MV inflow variation]]
*Pericardial effusion
**In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
**Differentiate pericardial effusion from pleural effusion using the parasternal long axis view.  Pericardial effusions will have an anechoic stripe between the left atrium and descending thoracic aorta.  In a pleural effusion, the stripe will be seen behind the descending thoracic aorta.<ref>Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982</ref>
*Classical ultrasound findings
**Diastolic collapse of the right atrium (in atrial diastole)
**Diastolic collapse of the right ventricle
**Plethoric IVC (highly sensitive but low specificity)<ref>What echocardiographic findings suggest a pericardial effusion is causing tamponade?  Am J Emerg Med. 2019 Feb;37(2):321-326. doi: 10.1016/j.ajem.2018.11.004. Epub 2018 Nov 17.</ref>
*Evaluating systolic vs. diastolic phases with M-mode
**Position in PSL view with M-mode line through where RV appears to collapse
**Allow M-mode line to pass through where the anterior MV hits the septum in diastole (much like evaluation of EPSS - see [[Formal echocardiography]])
**The period of time where the anterior leaflet of the mitral valve is open (and closest to the septum) is the period of diastole. Evaluate the anterior free wall of the right ventricle for collapse. The longer period of collapse during diastole is an indicator for advanced tamponade physiology 
*Valvular pulsus paradoxus
**Obtain apical 4-chamber view, place doppler indicator in either MV or TV location
**Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow
**MV inflow respiratory variation, difference from highest velocity to lowest, as a percentage of highest velocity<ref>Rajagopalan N, Garcia MJ, Rodriguez L, Murray RD, Apperson-Hansen C, Stugaard M, Thomas JD, and Klein AL. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol. 2001 Jan 1;87(1):86-94.</ref>
***> 25%, likely tamponade physiology
***> 40% for tricuspid inflow variation
***Helpful in thickened RV and RA from longstanding pulmonary hypertensive patients

==Management==
===Hemorrhagic Tamponade===
*Can occur if ECG read as STEMI/NSTEMI and heparin started
*[[Pericardiocentesis]]
**Temporizing measure until [[thoracotomy]] can be performed
*[[IVF]] to increase RV volume and maintain preload
*Medications
**[[Pressors]] (temporizing)
**Avoid preload reducing medications ([[nitroglycerin]], [[diuretics]])

===Non-hemorrhagic Tamponade===
*[[IVF]] bolus of 500-1000 ml (patient is pre-load dependent)
*[[Pericardiocentesis]] is definitive treatment
*Dialysis for patients with known [[renal failure]]

==Disposition==
*To OR if traumatic and hemodynamically unstable
*Admit with cardiology/CT surgery consult

==See Also==
*[[Pericardiocentesis]]
*[[Thoracic Trauma]]
*[[Pericarditis]]
*[[Cardiac ultrasound]]

==External Links==
*[https://emedicine.medscape.com/article/152083-overview#showall Medscape - Cardiac Tamponade]

==References==
<references/>

[[Category:Cardiology]]