09/02/2011

Clinical features of tamponade

Becks triad hypotension, raised JVP, quiet heart sounds Pulsus paradoxus (>10 mmHg drop in BP with inspiration) All difficult in acutely ill patients

PERICARDIAL AND PLEURAL EFFUSIONS

Stephen Glen

Echo signs to look for

2 1 3

IVC

The best views to diagnose, are also the best to drain A4Ch

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Subcostal

Parasternal to diagnose only

The size of the effusion

Useful for drainage (> 2 cm) Not always associated with compression Rapidity of onset more important

You dont want to see this during pericardial tap..

Case
52 yrs, female Increasing dyspnoea and fatigue Previous mastectomy for breast CA On regular tamoxifen

Examination
BP 130/80 P 90/min JVP elevated No respiratory variation in BP or pulse

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A4Ch

Immediate drainage required?

1. Yes 2. No 3. Unsure

Management

Case

No clinical evidence of tamponade CT chest effusion only, no mass lesion Drained for diagnostic and therapeutic effect Cytology recurrent of breast CA Subsequent chemotherapy (no recurrence of effusion)

Female, 57 yrs Sudden collapse with associated dyspnoea Background of pleuritic chest pain, myalgia Known HIV +ve On retroviral therapy

Examination
GCS 14/15 SaO2 96% (15 litres)

A4ch

BP 94/50 -> 75/40 on inspiration Pulse 90-130 /min HS inaudible JVP elevated Chest clear

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Subcostal

Immediate drainage required?

1. Yes 2. No 3. Unsure

Pericardiocentesis, or love in the procedure room?

Progress
Successful drainage Cytology confirmed Kaposis sarcoma a cause of haemorrhagic pericardial effusion in HIV positive patients Mediastinoscopy directed pericardial window

Confusing case
62 yrs, male Known lung CA due for resection (right apex)

Examination
Unwell, GCS 15 SaO2 81% (15 litres)

Sudden onset dyspnoea and palpitations Associated left pleuritic chest pain Recent preoperative chemotherapy No other PMH

p130/min (sinus) BP 80/40 HS inaudible Chest tachypnoeic, no crackles heard Abdo normal

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Focused echo, A4ch

Which is true?
1. There is right atrial collapse 2. There is right ventricular collapse 3. There is left atrial collapse 4. There is no echo evidence of tamponade 5. Unsure

A4ch, colour

Subcostal

PSAX

Immediate drainage required?

1. Yes 2. No 3. Unsure

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Management
CTPA confirmed central pulmonary embolism Pericardial effusion considered contraindication to thrombolysis Anticoagulated with heparin Effusion did not increase in size but right atrial collapse developed as pulmonary artery pressure fell, clinical evidence of tamponade Pericardial drain inserted Malignant cells identified in aspirate

Case
71 yrs, female Severe dyspnoea Background of COPD with home nebuliser PMH hypertension Rx irbesartan, salbutamol, atrovent, recent prednisolone, aspirin, simvastatin Smoker

Examination

Focused ultrasound, A4ch

GCS 15 SaO2 88% (24%, 2 litres) BP 168/90 JVP not visible HS inaudible Chest silent chest (left), widespread wheeze (right) Abdo normal

Is this pericardial or pleural?

1. Pericardial 2. Pleural 3. Both 4. Unsure

A4ch, lateral view

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Management
CXR confirmed left lung whiteout Ultrasound guided drain insertion Haemorrhagic exudate Cytology bronchial CA Hilar lesion identified after drainage on CT Chemotherapy started

Case
38 yrs, male Known Marfan syndrome Aortic root and valve replacement 3/12 ago Good postop recovery Dental work 3/52 ago without antibiotic prophylaxis Admitted in extremis

Examination

Focused echo, PLAX

GCS 8/10 (E2M4V2) 38.4C SaO2 91% (15 litres) BP 60/? P109/min (sinus) HS loud systolic murmur (aortic area) Chest reduced air entry left base and mid zone

Is this pericardial or pleural?

1. Pericardial 2. Pleural 3. Both 4. Unsure

PSAX

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Management
CT thoracic aortogram confirmed dehiscence Contrast leak into mediastinum, pericardium, lung Immediate cardiac surgery to repair Swabs at surgery confirm strep. Bovis growth 6/52 inpatient antibiotic therapy Subsequent echo

PLAX during longterm follow-up

Case

19 yrs, male Sharp left parasternal chest pain Recent myalgia, fever, nausea, diarrhoea No other PMH No regular Rx

Thrombolysis or pPCI?
1. Thrombolysis in A&E 2. Transfer for pPCI (about 60 mins journey) 3. Neither 4. Unsure

Focused echo, A4ch

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PSAX

PLAX

Is this pericardial or pleural?

1. 2. 3. 4. 5.

Management

Pericardial Pleural Both Neither Unsure

Clinical pericarditis Started on regular ibuprofen and colchicine Inflammatory markers Repeat echo in 7 days Manage as outpatient

Case
Male, 52 yrs Chest, back and abdominal pain PMH Hypertension, AF Rx Simvastatin, perindopril, warfarin, diltiazem Smokes 60/day No alcohohohol for at leasht a day (according to patient)

Examination
Pale, unkempt GCS 14

SaO2 98% (air) BP 90/48 P58/min (sinus) HS included harsh ejection systolic murmur Chest clear Abdomen- diffuse guarding, no bowel sounds

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Focused echo, PLAX

Is this pericardial or pleural?

1. Pericardial 2. Pleural 3. Both 4. Neither 5. Unsure

PLAX, colour

Abdomen

Abdomen

Abdomen

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Management
CT aorta (root to knees) Ascending aortic dissection, false lumen to iliacs, infrarenal aneurysm Contrast into mediastinum, pleura Accepted for surgery Anticoagulation reversed Limited surgical repair to dissection flap Continues medical therapy

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