Pericardial Effusion and Cardiac Tamponade

By Siti Hamidah Binti Abd Aziz

Pericardial Effusion
Is a collection of fluid within the potential space of the serous pericardial sac
(Kumar and Clarks Clinical Medicine)

Aetiologies
Idiophatic Infectious (pericarditis)
Viral Bacterial Tuberculous Fungal

Malignancy Cardiac causes

Aortic dissection CHF Post cardiac surgery

Immune mediated
SLE Systemic amyloidosis

Traumatic Radiation Renal

Uraemic pericarditis

Endocrine
Myxedema in hypothyroid

Pericardial Effusion

Mild

Moderate

Severe

Hemodynamically stable

Hemodynamically unstable

Cardiac Tamponade (symptomatic, medical emergency)

Cardiac Tamponade
Is when accumulation of pericardial within the pericardial space creates an increase in intrapericardial pressure leading to restriction in cardiac filling and decrease in cardiac output.

Classification of Cardiac Tamponade

Acute Rapid fluid accumulation Small effusion Becks triad Subacute Gradual fluid accumulation Large effusion More subtle presentation

Causes: cardiac/great vessels trauma, invasive procedures

Causes: neoplastic disease, tuberculosis, uraemia, or idiopathic disease

Symptoms
Dyspnea Reduced effort tolerance Chest pain Palpitation Abdominal pain (dt hepatic congestion) Confusion (dt reduce cardiac output)

Signs
Becks Triad
Hypotension Increased JVP Soft and distant heart sounds (heart sound is tampered by the large fluid)

Tachycardia, tachypnea Impalpable apex beat Pulses paradoxus (a drop in SBP10 mmHg during inspiration)

 Kussmauls sign (increase JVP during inspiration) Ewarts sign (dullness to percussion below the angle of left scapula dt effusion compressing basal left lung) S3 (not heard)

Investigations
ECG = low voltage QRS complexes, electrical alternans, tachycardia
QRS complex alternates upward and downward

QRS complex low than calibration

QRS complex alternates high and low voltage bec heart is moving anteriorly and posteriorly

 CXR = enlarged globular heart, water-bottleshaped cardiac silhoutte

 Echo = best way to confirm diagnosis

Effusion (pericardial fluid) Tamponade (swinging heart,RA systolic collapse, RV diastolic collapse) Pulsus paradoxus (different bt mitral and tricuspid inflow)

 Lab tests
FBC = infective cause of effusion ESR, CRP = inflammatory cause of effusion Cardiac enzymes = cardiac trauma/ MI

Management
Hemodynamically stable = resolve spontaneously or with NSAIDs, observation Hemodynamically instable (SBP<90mmHg, pulsus
paradoxus>10mmHg, effusion>20mm, RV collapse)

Immediate drainage Treat cause IV fluid, medication to maintain BP

Pericardiocentesis

Pericardiocentesis
Can be echo guided, mostly echo for monitoring Fluid drained can be sent for culture and cytology CI = aortic dissection; relative CI = severe coagulopathy Cx = laceration of the coronaries or myocardium, laceration of the viscera (i.e., liver), air embolus, pneumothorax, peritoneal puncture, arrhythmias

Complications
Recurrent effusion Organ hypoperfusion (renal failure) Cardiac arrest Effusive-constrictive pericarditis

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