Management of Cardiac Tamponade
Cardiac tamponade is a cardiovascular emergency that occurs when fluid accumulates in the intrapericardial space and impairs cardiac filling. Prompt recognition and diagnosis of cardiac tamponade using physical exam and bedside echocardiography is critica
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David D. Berg, Gregory W. Barsness, and Benjamin A. Olenchock
Case Presentation A 64-year-old man with a remote history of stage IIIa adenocarcinoma of the lung treated with chemotherapy and radiation presented to the emergency department complaining of left-sided chest pain and dyspnea. He had been diagnosed with a pulmonary embolism 2 weeks prior and was started on warfarin at that time. He felt well until the night before his current presentation when he became acutely dyspneic while lying in bed. His triage vital signs were notable for a heart rate of 106 beats per minute (bpm), blood pressure of 92/70 mmHg, and respiratory rate of 28 breaths per minute. A pulsus paradoxus of 18 mmHg was measured by manual sphygmomanometer. A 12-lead ECG showed sinus tachycardia with
Electronic supplementary material The online version of this chapter (doi:10.1007/978-3-319-43341-7_14) contains supplementary material, which is available to authorized users. D.D. Berg • B.A. Olenchock (*) Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA e-mail: [email protected] G.W. Barsness Department of Cardiovascular Diseases, Division of Ischemic Heart Disease and Critical Care Cardiology, Mayo Clinic, Rochester, MN, USA
low-normal QRS voltages (Fig. 14.1). A chest x-ray showed stable reticular opacities in the right middle and lower lobes at the sites of prior radiation treatment, as well as a prominent cardiomediastinal silhouette. A bedside echocardiogram was performed which showed a large circumferential pericardial effusion with early right ventricular (RV) diastolic collapse and exaggerated reciprocal respiratory variation in mitral and tricuspid early-diastolic inflow velocities (Fig. 14.2 and Video 14.1). Question What is the appropriate next step in the management of the patient’s pericardial effusion? Answer With few exceptions, patients with clinical and supportive echocardiographic evidence of cardiac tamponade should undergo emergent drainage of the pericardial effusion by percutaneous needle pericardiocentesis. Isotonic fluids can modestly increase cardiac output and mean arterial pressure in about half of patients with tamponade [1], but the results are generally transient, and this intervention should not substitute for or delay pericardiocentesis. In this case, the patient was given a 500 mL bolus of normal saline over 10 min with transient improvement in his systolic blood pressure. The cardiac catheterization laboratory was activated and the patient was given two units of fresh
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_14
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Fig. 14.1 Admission ECG Fig. 14.2 Pulse-wave Doppler of mitral inflow in the apical four chamber view, showing >25 % respirophasic variation in diastolic inflow velocities
f rozen plasma to reverse a supratherapeutic INR of 4.2. The pericardial space was accessed through a subxiphoid
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