Cardiac Tamponade And Pericardial Effusion

Front 1

Definition of tamponade.

Back 1

An elevation of intrapericardial pressure due to the accumulation of pericardial effusion which results in an elevation of intracardiac pressures, progressive limitation of ventricular diastolic filling and reduction in stroke volume.

Front 2

What two factors influences the likelihood of getting tamponade?

Back 2

Volume of fluid.
Rate of fluid accumulation.

Front 3

What are the consequences of tamponade?

Back 3

Pericardial compression results in:
Impaired filling
Low cardiac output.

Front 4

Why does tamponade result in impaired filling and low cardiac output?

Back 4

The increased intrapericardial pressure compresses the cardiac chambers.

Front 5

What is impaired due to cardiac tamponade?

Back 5

Ventricular diastolic filling.

Front 6

What happens to stroke volume in cardiac tamponade?

Back 6

Stroke volume decreases, because ventricular diastolic filling is reduced.

Front 7

What happens to heart rate with cardiac tamponade?

Back 7

Heart rate increases to compensate for low cardiac output.

Front 8

Can echo make a conclusive diagnosis of cardiac tamponade?

Back 8

No, but it plays a significant role.

Front 9

What are potential end results of cardiac tamponade?

Back 9

Hypotension
Shock (hypovolumic)
Sudden death

Front 10

Which chambers are compressed in tamponade?

Back 10

Atria during systole
Ventricles during diastole
Happens sequentially, when their pressures are lowest.

Front 11

5 echo findings with a moderate to large effusion?

Back 11

RA collapse
RV collapse
Reciprocal respiratory changes in RV and LV volumes.
Reciprocal respiratory changes in RV and LV filling.
IVC plethora.

Front 12

When does right atrial collapse or inversion occur?

Back 12

You see a collapse or inversion when intrapericardial pressure exceeds RA systolic pressure.
The RA free wall collapses.
RA free wall is a thin, flexible structure, so brief RA wall inversion can occur in the absence of tamponade.

Front 13

Is RA collapse ever indicative of tamponade?

Back 13

Increased duration of collapse supports tamponade physiology.
If it is collapsed for at least 1/3rd of systole, it supports the diagnosis of tamponade.
Duration can be seen on M-mode.

Front 14

When does RV collapse occur?

Back 14

Diastole.

Front 15

What effect does tamponade have on RV thickness and compliance?

Back 15

None. Compliance and thickness are not affected.

Front 16

is RV or RA collapse a more positive indication of tamponade?

Back 16

RV collapse, because it takes greater pressure to collapse a ventricle.

Front 17

What is the normal range off intrapericardial pressure?

Back 17

Between 5 and -5mmHg.

Front 18

What causes a fluctuation of intrapericardial pressure?

Back 18

Respiration.

Front 19

With inspiration, what happens to intrathoracic pressure?

Back 19

Decreases

Front 20

With inspiration, what happens to intrapericardial pressure?

Back 20

Decreases

Front 21

What effect does inspiration have on the heart?

Back 21

It increases flow to the right heart and reduces venous flow to the left heart.

Front 22

What happens to L and R stroke volume upon inspiration?

Back 22

Right SV increases.
Left SV decreases.

Front 23

What happens to intrathoracic pressure with expiration?

Back 23

Increase

Front 24

What happens to intrapericardial pressure with expiration?

Back 24

Increase

Front 25

With expiration, what happens to RV filling?

Back 25

Mild decrease.

Front 26

With expiration, what happens to LV filling?

Back 26

Increase.

Front 27

How much pressure change is seen with inspiration?

Back 27

Does not exceed 10mmHg.

Front 28

What is the effect of increased pericardial fluid on volume of blood?

Back 28

Less blood volume is allowed into all chambers.
This exaggerates the respiratory dependent ventricular volume interaction.

Front 29

When does diastolic pressure in all chambers equalize?

Back 29

When intrapericardial pressure exceeds normal filling pressure, so filling pressure is then determined by the intrapericardial pressure.

Front 30

How is the equalization of pressure helpful?

Back 30

The increase helps to maintain stroke volume.

Front 31

Which ventricle is impaired more with tamponade?

Back 31

RV, because the LV is more stiff.

Front 32

When does respiratory variation become significant?

Back 32

When there is a greater than 25% variation.

Front 33

In tamponade, what happens to PA flow with inspiration?

Back 33

Increases.

Front 34

In tamponade, what happens to Ao flow with inspiration?

Back 34

Decreases.

Front 35

What happens to hepatic reversal with inspiration in tamponade?

Back 35

Increases with expiration.

Front 36

Why is there an increase with expiration of hepatic reversal?

Back 36

Because reduced forward flow augments reversal.

Front 37

What is paradoxical septal motion?

Back 37

Left ventricular walls more parallel to one another rather than contracting and expanding simultaneously.

Front 38

How can respiratory variation be evaluated?

Back 38

M-mode.

Front 39

In tamponade, how does the septum move during inspiration?

Back 39

Toward the LV due to increased RV filling.

Front 40

In tamponade, how does the septum move during expiration?

Back 40

Toward the RV due to increased LV filling. More a normalization from inspiratory movement toward LV

Front 41

Why is there a decrease in systolic blood pressure with tamponade? When does this happen?

Back 41

Because of the decreased SV in the LV.
Happens during inspiration.

Front 42

What is pulses paradoxis?

Back 42

A clinical finding in cardiac tamponade, where there is a decrease in systolic blood pressure of more than 10mmHg upon inspiration.
May also find a narrow pulse pressure due to low systolic pressure and elevated diastolic pressure.

Front 43

What are signs of elevated venous pressures with tamponade?

Back 43

JVD,
IVC plethora - dilated with less than 50% reactivity, indicates elevated right sided pressure.

Front 44

What is Beck's Triad?

Back 44

Elevated venous pressure.
Hypotension.
Quiet Heart.

Front 45

What is Ewart Sign?

Back 45

Dullness to percussion, atelectasis (collapsed lung)

Front 46

What is atelectasis?

Back 46

Collapsed lung.

Front 47

Why do you get tachycardia with tamponade?

Back 47

Heart trying to compensate to increase CO.

Front 48

What are 3 symptoms of low CO?

Back 48

Syncope
Cyanosis
Confusion.

Front 49

List 11 clinical findings of tamponade.

Back 49

Pulsus paradoxis
Narrow pulse pressure
Hypotension
Low CO
Elevated venous pressure
Tachycardia
Chest pain, anxiety, hoarseness, confusion
Ewart sign
Beck's Triad
Electrical alternans: swinging heart.

Front 50

What is electrical alternans?

Back 50

Swinging heart - beat to beat variation of QRS height.

Front 51

2D findings of tamponade?

Back 51

Moderate to large pericardial effusion
RA collapse greater than 1/3rd of systole
RV collapse during diastole
Reciprical changes in RV and LV volumes with respiration
IVC plethora
May see swinging heart.

Front 52

Doppler findings in tamponade?

Back 52

Respiratory variation in Right and Left ventricular filling greater than 25%.
Respiratory variation of outflow velocities.

Front 53

What are the respiratory variations of outflow velocities with inspiration?

Back 53

Aortic decreases
Pulmonary vein decreases
Hepatic increases
Pulmonary artery decreases.

Front 54

What echo finding can exclude the diagnosis of tamponade?

Back 54

Lack of pericardial effusion.
No effusion, no tamponade.

Front 55

What is pericardiocentesis?

Back 55

Removal of the fluid. The only thing that will save the patient.