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Cardiac Tamponade (Causes (Trauma (Blunt/penetrating (Clinical signs may…
Cardiac Tamponade
Causes
Trauma
CVC insertion
Minimisation of risk
Strategy
Careful catheter insertion, no advancing if resistance is met
Fluoroscopy guidance or CXR immediately post to confirm tip position
Remove catheter when no longer required
Generally right sided insertion will result in more direct course of catheter
Assess patient and insertion site to determine desired tip position/length
Risk is minimised if tip is outside pericardial refelction
Suspect in upper abdo trauma with hypotension
Blunt/penetrating
Clinical signs may be masked in trauma (collar/supine)
Pericardiocentesis may fail if blood clotted
FAST U/S or TOE for diagnosis
Cardiac surgery
Migration of pacing wire
Underlying disease
Renal fail, cancer, TB + pleuritic pain/hypotension
Reversible cause in any cardiac arrest
Presentation (depends on the severity and rapidity of tamponade)
General symptoms: chest pain, dyspnoea, poor periph perfusion, restlessness, confusion to LOC, cardiac arrest
CVS symptoms: tachyc, hypot, JV distension, JVP lacks usual y-descent, muffled heart sounds, pulsus paradoxus, raised LA pressure/CVP, impaired periph perfusion
Progress to obstructive shock - usually PEA arrest
Investigations
ECG - small complexes, electrical alterans
CXR - may see globular and enlarged heart shadow and clear lung fields
Echo - definitive Ix
Volume of fluid between pericardium and myocardium
Heart may swing excessively in sac
Early RV diastolic collapse
Late diastolic atrial collapse
Resp variation in diastolic filling
Management
Supportive care
Inotropes
Avoid IPPV (any cause reduced VR)
Pericardiocentesis
Guided by U/S
Para xiphoid approach (aim for L shoulder)
Pigtailed catheter for prolonged drainage
+/- subseq surgery for definitive mgmt
Subcostal incision
Pericardial window if risk of reaccumulation
Anaesthetic concerns
Avoid drugs/manoeuvers that reduce VR
Maintain HR (CO dependent on this in compromised SV)
Maintain contractility (avoid myocardial depressant)
Maintain/restroe volume status
Caution using IPPV
Definition
Compression of the heart by fluid within the pericardium. Restricts ventricular filling (reduces SV and CO)
Medical emergency requiring simultaneous Ix and Mx
May be slow or rapid - rate of accumulation often more important than absolute volumes