Lecture notes for medical students

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2. Learning Objectives

3. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.
•

5. Introduction & History.
• Cardiac tamponade is cardiac dysfunction
caused by external compression of heart by
the accumulation of excessive contents in
the pericardial space.
• May be effusion fluid, blood, clot, pus, gas
singly or in combination.
• The condition is a medical emergency, the
complications of which include pulmonary
edema, shock, and death.

6. Terminology

7. Terminology
• Cardiac tamponade .
• Acute Pericarditis
• Pericardial effusion
• Constrictive Pericarditis
• Effusive-Constrictive Pericarditis.

8. Acute pericarditis

9. Acute pericarditis
An inflammation of the pericardium
characterized by
• Pericarditic chest pain
• Pericardial friction rub
• Serial ECG changes
– New widespread st-elevation
– PR depression
• New/worsening pericardial effusion

10. Pericardial effusion
• Pericardial effusion is the presence of an
abnormal amount of fluid and/or an
abnormal character to fluid in the
pericardial space.

11. Constrictive Pericarditis
• Pericardial inflammation, chronic fibrotic
scarring, calcification,

12. Effusive-Constrictive Pericarditis

13. Effusive-Constrictive Pericarditis
• The hemodynamic definition of this
syndrome is the continued elevation of right
atrial, end-diastolic right ventricular, and
left ventricular diastolic pressures after the
removal of pericardial fluid returns the
pericardial pressure to zero

14. Aetiology

15. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

16. Aetiology
• Idiopathic
• Congenital/Genetic
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative
• Iatrogenic

17. Aetiology
• Tuberculosis
• Penetrating chest injury
• Malignancy
• Uremia
• Idiopathic pericarditis
• Infectious diseases
• Anticoagulation
• Connective tissue diseases
• Dressler or postpericardiotomy syndrome
• Pericarditis.

18. Pericarditis Aetiology
Iatrogenic
• Drugs - Hydralazine,
procainamide,
isoniazid, minoxidil
• Acupuncture
• Radiation therapy
• Cardiac procedures
• Anticoagulation
treatment
• antireflux surgery
• HIV
• Postmyocardial
infarction
• Trauma to the chest
• Uremia
• Connective tissue
diseases
• Idiopathic pericarditis

19. Pericarditis:Aetiology
• Hypothyroidism
• Still disease
• Duchenne muscular dystrophy
• Streptococcus constellatus infection .
• Pneumopericardium -
– -mechanical ventilation
– gastropericardial fistula
•

20. Pathophysiology

21. Pathophysiology
• Pericardium has two layers .
• Normally contains 15-35ml. Fluid.
• Parietal paricardium is inelastic.
• Acute accumulation of any content raises
pressure while slow accumulation is
tolerated.
• Key defect is obstruction to diastolic
distension of all chambers leading to
reduction of filling.

22. Pathophysiology
• Congestive heart failure (CHF), especially
right-sided heart failure
• Cardiac output gradually becomes
inadequate at first with exercise and then at
rest.

23. Clinical Features
•

24. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

25. Demography

26. Demography
• 2 per 10,000 population in the US.
• Approximately 2% of penetrating injuries
are reported to result in cardiac tamponade.
• In children- male-to-female ratio of 7:3.
• In adults slightly more common in men than
in women.
• Cardiac tamponade related to trauma or
HIV is more common in young adults,
• tamponade due to malignancy and/or renal
failure occurs more frequently in elderly
individuals.

27. Symptoms

28. Symptoms
• Acute tamponade –
– Dyspnea
– Tachycardia
– Tachypnea
– decreased urine output
– and/or confusion
– Cold and clammy extremities from
hypoperfusion
• Symptoms of primary disease- probable
etiology of a pericardial effusion. weight
loss, fatigue, or anorexiaChest pain ,

29. Demography

30. Demography
• Incidence & Prevalence
• Geographical distribution.
• Race
• Age
• Sex
• Socioeconomic status
• Temporal behaviour

31. Symptoms

32. Symptoms
• Acute tamponade –
– Dyspnea
– Tachycardia
– Tachypnea
– decreased urine output
– and/or confusion
– Cold and clammy extremities from
hypoperfusion
• Symptoms of primary disease- probable
etiology of a pericardial effusion. weight
loss, fatigue, or anorexiaChest pain ,

33. Signs

34. Signs
• Beck triad also called the acute
compression triad
–Increased jugular venous pressure,
–Hypotension
–Diminished heart sounds

35. Signs
Pulsus paradoxus
• An exaggeration (>12 mm hg or 9%) of the
normal inspiratory decrease in systemic
blood pressure.
• The paradox is that while listening to the
heart sounds during inspiration, the pulse
weakens or may not be palpated with
certain heartbeats, while S1 is heard with all
heartbeats.

36. Signs
• Kussmaul sign- a paradoxical increase in
jugular venous distention and pressure
during inspiration.
• Ewart sign- AKA the Pins sign-
– an area of dullness
– with bronchial breath sounds
– bronchophony below the angle of the left
scapula.
• The y descent- abolished in the jugular
venous or right atrial waveform.

37. Signs
• Pericardial friction rub
• Hepatomegaly
• Tachycardia

38. The y descent- abolished in the jugular venous
or right atrial waveform.

39. Signs
• Low-pressure tamponade-In severely
hypovolemic patients, classical physical
findings such as tachycardia, pulsus
paradoxus, and jugular venous distention
are infrequent.

40. Prognosis

41. Prognosis
• Cardiac tamponade is a medical emergency.
The prognosis depends on prompt
recognition and management of the
condition and the underlying cause of the
tamponade.
• Untreated, cardiac tamponade is rapidly
and universally fatal.

42. Complications

43. Complications
• Pulomnary oedema.
• Cardiogenic shock.
• Death.

44. Investigations

45. Investigations
• Laboratory Studies
– Routine
– Special Montoux test
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology- pericardial biopsy

46. Diagnostic Studies
Imaging Studies

47. Diagnostic Studies
Imaging Studies
• X-Ray- Cardiomegaly.
• USG- Echocardiography
• CT
• Angiography- Swan- ganz catheterization.
• MRI
• Endoscopy
• Nuclear scan

48. Diagnostic Studies
ECG- suggestive only
• Sinus tachycardia
• Low-voltage QRS complexes
• Electrical alternans - Also observed during
supraventricular and ventricular tachycardia
• PR segment depression

49. water bottle–shaped heart

50. X-Ray Chest
• water bottle–shaped heart
• pericardial calcifications
• evidence of chest wall trauma.

51. Differential Diagnosis

52. Differential Diagnosis
• Myocardial infarction
• Large pleural effusion
• tension pneumothorax
• respiratory failure
• Pulmonary Embolism
• pneumopericardium

53. Management

54. Management
1.Removal of pericardial fluid
• Emergency Pericardiocentesis-subxiphoid
percutaneous drainage
• Percutaneous balloon pericardiotomy
2. Treatment of cause eg
-ATT forTuberculosis.
-NSAIDs.colchicine

55. Operative Therapy

56. Operative Therapy
• Pericardiectomy
• Pericardio- Peritoneal window.

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