S2: Ch1 Cv 2-3

Front 1

349. Diagnosis of Pericardial effusion?

Back 1

a. Echo: Imaging procedure of choice: confirms the presence or absence of a significant effusion.
i. Most sensitive and specific method of determining whether pericardial fluid is present; can show as little as 20 ml of fluid.
b. CXR
c. ECG
d. CT or MRI
e. Pericardial fluid analysis

Front 2

350. Echo for Pericardial effusion?

Back 2

a. Echo: Imaging procedure of choice: confirms the presence or absence of a significant effusion.
b. Most sensitive and specific method of determining whether pericardial fluid is present; can show as little as 20 ml of fluid.

Front 3

351. CXR for Pericardial effusion?

Back 3

a. Shows enlargement of cardiac silhouette when >250 ml of fluid has accumulated.
b. Cardiac silhouette may have prototypical “water bottle” appearance.
c. An enlarged heard w/out pulmonary vascular congestion suggests pericardial effusion.

Front 4

352. ECG for Pericardial effusion?

Back 4

a. Shows low QRS voltages and T wave flattening but should not be used to diagnose pericardial effusion.
b. Electrical alternans suggests a massive pericardial effusion and tamponade.

Front 5

353. CT scan or MRI for Pericardial effusion?

Back 5

a. Very accurate, but often unnecessary given the accuracy of an echo.

Front 6

354. Pericardial fluid analysis for Pericardial effusion?

Back 6

a. May clarify cause of effusion.

Front 7

355. Tx of pericardial effusion?

Back 7

a. Depends on pt’s hemodynamic stability
b. Pericardiocentesis is not indicated unless there is evidence of cardiac tamponade. Analysis of pericardial fluid can be useful if the cause of the effusion is unknown.
c. If the effusion is small and clinically insignificant, a repeat echo in 1-2 wks is appropriate.

Front 8

356. What is important w/respect to cardiac tamponade?

Back 8

a. The RATE of fluid accumulation, not the amount.
b. 200 ml of fluid that develops rapidly can cause cardiac tamponade.
c. 2L of fluid may accumulate slowly before tamponade occurs. (it is able to stretch and adapt.

Front 9

357. Pathophys of cardiac tamponade?

Back 9

a. Pericardial effusion that impairs diastolic filling of the heart.
b. Characterized by the elevation and equalization of intracardiac and intrapericardial pressures.
c. Pressures in the RV, LV, RA, LA, pulmonary A, and pericardium equalize during diastole.
d. Ventricular filling is impaired during diastole!!!!!
e. Decreased diastolic filling leads to ↓ SV and ↓CO

Front 10

358. Causes of Cardiac Tamponade?

Back 10

a. Penetrating (less commonly blunt) trauma to the thorax.
b. Iatrogenic: central line placement, pacemaker insertion, pericardiocentesis, etc.
c. Pericarditis
d. Post-MI w/free-wall rupture.

Front 11

359. Clinical features of cardiac tamponade?

Back 11

a. Elevated jugular venous pressure is the most common finding (distended neck veins).
b. Narrowed pulse pressure (due to ↓ SV)
c. Pulsus paradoxus
d. Distant (muffled) heart sounds
e. Tachypnea, tachycardia, and hypotension w/onset of cardiogenic shock.

Front 12

360. Venous waveforms w/tamponade?

Back 12

a. Prominent X descent w/absent y descent are seen.

Front 13

361. Pulsus paradoxus?

Back 13

a. Exaggerated decrease in arterial pressure during inspiration (>10 mm Hg drop)
b. Can be detected by a decrease in the amplitude of the femoral or carotid pulse during inspiration.
c. Pulse gets strong during expiration and weak during inspiration.

Front 14

362. What does constrictive pericarditis often progress to?

Back 14

a. Worsening cardiac output and to hepatic and/or renal failure.
b. Surgical tx is indicated in most cases.

Front 15

363. Imaging study of choice for dx of pericardial effusion and tamponade (high sensitivity)?

Back 15

a. Echo.

Front 16

364. Note: Pericardial effusion is important clinically when it develops rapidly bc it may lead to cardiac tamponade.

Back 16

364. Note: Pericardial effusion is important clinically when it develops rapidly bc it may lead to cardiac tamponade.

Front 17

365. Beck’s triad (cardiac tamponade)?

Back 17

a. Hypotension
b. Muffled heart sounds
c. JVD.

Front 18

366. Dx of cardiac tamponade?

Back 18

a. Echocardiogram
b. CXR
c. ECG
d. Cardiac Catheterization

Front 19

367. Echo for cardiac tamponade?

Back 19

a. Must be performed if suspicion of tamponade exist based on history examination.
b. Usually diagnostic; the most sensitive and specific non-invasive test.

Front 20

368. CXR for cardiac tamponade?

Back 20

a. Enlargement of cardiac silhouette when >250 ml has accumulated.
b. Clear lung fields

Front 21

369. ECG for cardiac tamponade?

Back 21

a. Electrical alternans (alternate beat variation in the direction of the ECG wave-forms) - due to pendular swinging of the heart w/in Pericardial space, causing a motion artifact.
b. Findings are neither 100% sensitive nor specific. ECG should not be used to diagnostic tamponade.

Front 22

370. Cardiac catheterization for tamponade?

Back 22

a. Shows equalization of pressures in all chambers of the heart.
b. Shows elevated right atrial pressure w/loss of the y descent.

Front 23

371. Non-haemorrhagic tamponade?

Back 23

a. If pt if haemodynamically stable
i. Monitor closely w/echo, CXR, ECG.
ii. If pt has known renal failure, dialysis is more helpful than pericardiocentesis.
b. If pt is not hemodynamically stable:
i. Pericardiocentesis is indicated.
ii. If no improvement is noted, fluid challenge may improve symptoms.

Front 24

372. Haemorrhagic tamponade secondary to trauma?

Back 24

a. Emergent surgery is indicated to repair the injury
b. Pericardiocentesis is only temporizing measure and is not definitive treatment. Surgery should NOT be delayed to perform pericardiocentesis.