Tamponade

PATHO

  • Rapid accumulation of fluid in pericardial space ➔ compression of RV wall ➔ leftward septal shift ➔ ↓ filling ➔ venous congestions & ↓CO

  • Hemopericardium: MI ➔ myocardium rupture, chest trauma, aortic dissection, surgery

  • Serous effusion: Idiopathic, acute pericarditis, uremia, cancer, hypothyroid, autoimmune

SSX (they look bad)

  • Narrow pulse pressure, then hypotension & tachycardia

    • RV can't expand to accept that ↑ preload (effusion/tamponade) septum shifts ➔ ↓ LV filling ➔ ↓ SV

  • Pulsus paradoxus (↓ in systolic BP > 10 mmHg) - Normally, inspiration ➔ ↑ right sided preload & ↓ left sided preload ➔ small ↓ in BP

DX

  • Don't do any diagnostics if pt circling the drain

    • Bedside US with pericardiocentesis

    • Send for pericardial fluid analysis - transudative (low in protein) HF, RF, low albumin

  • ECHO (TTE > TEE) shows effusion (anechoic/echolucent space between epicardium and pericardium) and swinging heart

    • Chamber collapse (RA during systole & RV during diastole then LA collapses)

  • Pulmonary artery cath shows obstructive shock with ↑ PCWP

  • EKG (because they said chest pain): electrical alternans (from swinging heart ) & low voltage QRS complexes

TX

  • Unstable: Get an adult for pericardiocentesis

    • Subxiphoid approach: Long, large bore needle, inserted just under left coastal margin keeping a 30-45° angle . Aspirate while advancing toward left shoulder

  • Stable: US, CT, fluoroscopy guided pericardiocentesis ➔ ↓ risk