1. PERICARDIAL EFFUSION &CARDIAC TAMPONADEby DR. AVINASH PRAKASH

2. IMPORTANT POINTS Definition Patho-physiology etiology Clinical features Investigations Treatment 3. DEFINITION PERICARDIAL EFFUSION an abnormal accumulation of fluidin the pericardial cavity CARDIAC TAMPONADEclinical syndrome caused by accumulation of fluid in the pericardial space,resulting in reduced ventricular filling andsubsequent hemodynamic compromise 4. PATHO-PHYSIOLOGY Pressurepericardi on rt side al fluidof heart Poolingof blood Venous in pulm returncapillariesStrokevolume,Cardiac ArrestCOHow much pericardial fluid is needed to 5. Pericardial Pressure-Volume Relation 6. ETIOLOGY: blood/ pus/serous hypothyroidism physical trauma Pericarditis (bact/TB/HIV) myocardial rupture after heart surgery aortic dissection neoplastic 7. CLINICAL SYMPTOMS Breathles sness Chest pain, Abdomina l pain, Fatigue, Fever, Cough, Palpitati on, Maybe in 8. PHYSICAL EXAMINATION tachycardia, distant or muffledheart sounds jugular veindistension falling BP, paradoxical pulse (a drop in inspiratoryBP by greater than 10mmHg). 9. Becks triad.(rapid accumulation of pericardial fluid)1. Hypotension occurs because of decreased stroke volume2. jugular-venous distension due to impaired venous return to the heart3. muffled heart sounds due to fluid inside the pericardium 10. INVESTIGATIONS complete bloodcount (CBC) RFT,LFT PT,INR CKMB, TROP-T ANA assay, ESR Rh FACTOR HIV testing Mantoux test Pericardial fluid 11. ECG sinus tachy ,low voltage QRS complexes , electrical alterans, 12. CXR:large, globular heart, enlarge cardiacsilhouette, water bottle shaped heart 13. ECHO: diagnostic test of choice 14. TREATMENT: PERICARDIAL EFFUSIONThe mortality andMEDICINEmorbidity of NSAIDS/Aspirin : for most pericarditis effusion ispericardial Colchicine: COPE trialdependent uponetiology and comorbid Systemic steroids: causes recurrence ; only if unreconditions Hemodynamic support : IVF, Inotropes Pus? drain+ i.v. antibacterial therapy TB- ATT+ iv predni 1-2 mg/kg x 7 d Antineoplastic therapySURGERY (if S/S persist) Pericardial sclerosis (tetra , doxy ,cisplatin,5 FU Sub-xiphoid pericardial window with pericardiost Thoracotomy: pleuro-pericardial window Video-assisted thoracic surgery 15. TREATMENT: PERICARDIAL EFFUSIONMild/asympt No Rx; o/f/u ECHO incidentalKnownMedium/ cause Tampona large de No causeIdiopathic 16. TREATMENT: PERICARDIAL EFFUSIONPericardiocentesiS/Ss/ Sx DrainageKnownTreat the cause causeAsympt Asirin/ o NSAIDSNo role for elective pericardiocentesis in asymptomatic ,unless for diagnosis or if pus / TBDiagnosticpericardiocentesis 17. TREATMENT: PERICARDIAL EFFUSIONLarge effusion x 3 months Remove as much as possibleElective IdiopathicRecurrencepericardioce?Chronic ntesisRepeatPericardie Recurrence Pericardiocenctomy ?tesis 18. TREATMENT: CARDIAC TAMPONADECardiac tamponade is a medical emergency Untreated, cardiac tamponade is rapidlyand universally fatalPrompt diagnosis and treatment is the key. O2 Volume expansion Bed rest Inotropic drugs Positive-pressure mechanicalventilation should be avoided Pericardiocentesis: A Swan-Ganz catheter can be left inplace for continuous monitoring ofhemodynamics 19. PERICARDIOCENTESISEquipment1. Bed side ECHO2. ECG3. 18 gauge spinal needle4. 3 way5. 20 cc syringe6. A wire with alligator clips 20. PERICARDIOCENTESISPREPARATION:1. surface landmarks2. Clean3. Drape4. LA5. Raise the head of the bed 21. PERICARDIOCENTESISAPPROACH1. Sub-xiphoid : A. Echoguided B. ECGguided C. Blind2. Para- sternal 22. PERICARDIOCENTESISAFTER CARE1. Monitor vitals2. Look out for complications3. Repeat ECHO & CXR4. If Pt still symptomatic then may require placement of catheter in the pericardial space or surgical creation of a pericardial window 23. PERICARDIOCENTESISCOMPLICATIONS1. Cardiac arrhythmia2. Pneumothorax3. Pleural effusion4. Myocardial injury5. Peritoneal injury6. Liver/stomach injury7. Internal mammary artery injury8. Diaphragmatic injury 24. RECURRENT TAMPONADE pericardial window Sclerosing the pericardium Pericardio-peritoneal shunt Pericardiectomy 25. Signs & symptoms and management of TAKE HOME MESSAGE the rate of pericardial effusion depends on accumulation of effusion Elective pericardiocentesis is not warranted in all pericardial effusions Cardiac tamponade is a medical emergency, and if untreated, its rapidly and universally fatal Prompt diagnosis and treatment is the key. Pericardiocentesis is a life saving procedure in tamponade Monitor vitals after the procedure to look for