Pericardial tamponade

[yalemd]

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Once tamponade suspected clinically, what is the best next step in mangement; Echo or pericardiocentesis, and why? I'd say the second cause it is emergency case. What do you think?
Thanks

 

[Golding]

Once tamponade suspected clinically, what is the best next step in mangement; Echo or pericardiocentesis, and why? I'd say the second cause it is emergency case. What do you think?
Thanks

"Tamponade" in and of itself is an emergency. But you have to be careful what word you're using. The nonemergent version of a tamponade is pericardial effusion.

As you'll notice from a few question banks out there, Pericardial Tamponade is a clinical diagnosis made with Beck's Triad (hypotension+JVD+distant heart sounds). Distant heart sounds alone aren't enough, since Anterior MI can present similarly. Pulsus Paradoxus helps differentiate the two (present in Tamponade, not in Anterior MI). Once you've settled that it's most likely Tamponade based on the history and physical findings, you do the Pericardiocentesis. Taking the time with an Echo could kill the patient.

Pericardial Effusion's management can vary on etiology. You'll more likely find it on X-ray as a water-bottle shaped heart. Echo may be the next step, but it more or less depends.

 

[Fuzuli]

As you'll notice from a few question banks out there, Pericardial Tamponade is a clinical diagnosis made with Beck's Triad (hypotension+JVD+distant heart sounds). Distant heart sounds alone aren't enough, since Anterior MI can present similarly. Pulsus Paradoxus helps differentiate the two (present in Tamponade, not in Anterior MI). Once you've settled that it's most likely Tamponade based on the history and physical findings, you do the Pericardiocentesis. Taking the time with an Echo could kill the patient.

I have to disagree with this. In Harrison's (17/e, p1491), it explicitly states that "since immediate treatment of cardiac tamponade may be lifesaving, prompt measures to establish the diagnosis by echocardiography should be undertaken". In fact, pericardiocentesis is done by echo guiding.

 

[Golding]

I have to disagree with this. In Harrison's (17/e, p1491), it explicitly states that "since immediate treatment of cardiac tamponade may be lifesaving, prompt measures to establish the diagnosis by echocardiography should be undertaken". In fact, pericardiocentesis is done by echo guiding.

Echo is done if time allows for it, which it often doesn't. Fair point on Echo-guided Pericardiocentesis, but you ought to realize that the purpose of the procedure isn't the Echo.

In the (unusual in terms of frequency on exams) case that the patient is stable, I'd be more comfortable changing the answer to Echo. But otherwise, I think you'd be sorry to pick any answer other than Pericardiocentesis.

 

[yalemd]

In fact, that pt has:
Hx: of lung cancer
Sx: JVD, Hypotention and pulsus paradox. (But no distant heart sounds). CXR: Cardiomegaly (not specifically water-bottle app.)
EKG: electric alternans (present in effusion, not sure if presents in tamponade as well)
So based on that pitcure, Dx:effusion. Next Step:Echo?

Is there a sharp demarcation to know (w/o echo) i.e. clinically, if that is effusion or tamponade?

Thanks

 

[yalemd]

If the same patient w/ distant heart sounds (i.e. the 3 triad for tamponade) + pulsus paradox. Can we consider tamponade in Dx?

Thanks

 

[Fuzuli]

Echo is done if time allows for it, which it often doesn't. Fair point on Echo-guided Pericardiocentesis, but you ought to realize that the purpose of the procedure isn't the Echo.

In the (unusual in terms of frequency on exams) case that the patient is stable, I'd be more comfortable changing the answer to Echo. But otherwise, I think you'd be sorry to pick any answer other than Pericardiocentesis.

This is what I've disagreed with. You have presented cardiac tamponade as akin to AAA, which is not the case. Bedside emergency pericardiocentesis is performed in extreme situations. The common sequence of events in cardiac tamponade is physical examination > echocardiograhy and pericardiocentesis > right-sided catheterization (if appropriate)

I've looked this up in Cecil (23/e) as well, and it's written that "For patients in whom the history or physical examination suggests tamponade, emergency transthoracic echocardiography is imperative and generally diagnostic."

I guess the main problem at hand here is the cardiovascular stability of the patient. Obviously, an emergency bedside pericardiocentesis (among with other things) is necessary in a patient with BP of 60/30 mm Hg with no pulse, but this is not a common presentation of cardiac tamponade. In fact, many patients with cardiac tamponade do not present with hypotension.

 

[Fuzuli]

In fact, that pt has:
Hx: of lung cancer
Sx: JVD, Hypotention and pulsus paradox. (But no distant heart sounds). CXR: Cardiomegaly (not specifically water-bottle app.)
EKG: electric alternans (present in effusion, not sure if presents in tamponade as well)
So based on that pitcure, Dx:effusion. Next Step:Echo?

Is there a sharp demarcation to know (w/o echo) i.e. clinically, if that is effusion or tamponade?

Thanks

Tamponade is a manifestation of rapid fluid accumulation, so the DDx is not between effusion and tamponade, but between tamponade and constrictive pericarditis. In this patient, presence of pulsus paradoxus, hypotension and electrical alternans would favor cardiac tamponade caused by pericardial effusion due to metastatic lung cancer. The next step should be echocardiography with pericardiocentesis and pericardial fluid should be analyzed for presence of cancer cells by cytology; a complete cell count, microscopic examination and culture (both standard and Mycobacterial) should also be performed.

 

[yalemd]

Tamponade is a manifestation of rapid fluid accumulation, so the DDx is not between effusion and tamponade, but between tamponade and constrictive pericarditis. In this patient, presence of pulsus paradoxus, hypotension and electrical alternans would favor cardiac tamponade caused by pericardial effusion due to metastatic lung cancer. The next step should be echocardiography with pericardiocentesis and pericardial fluid should be analyzed for presence of cancer cells by cytology; a complete cell count, microscopic examination and culture (both standard and Mycobacterial) should also be performed.

What if the question states each as an option, which one would you go for?

I would say Echo., so you can r/o constrictive pericarditis as well.

FYI, the ''answer key''; Dx: effusion, not tamponade.

 

[Golding]

In fact, that pt has:
Hx: of lung cancer
Sx: JVD, Hypotention and pulsus paradox. (But no distant heart sounds). CXR: Cardiomegaly (not specifically water-bottle app.)
EKG: electric alternans (present in effusion, not sure if presents in tamponade as well)
So based on that pitcure, Dx:effusion. Next Step:Echo?

Is there a sharp demarcation to know (w/o echo) i.e. clinically, if that is effusion or tamponade?

Thanks

That sounds like Effusion coming from pericarditis secondary to the lung cancer. It's an ongoing thing, not really abrupt like Tamponade is. That does deserve an Echo if stable. Does the question list his vitals?

The demarcation to know is really a matter of clinical judgment. You'll see Cardiac Tamponade in trauma situations or post-MI. It's an acute picture rather than an ongoing one.

 

[Golding]

This is what I've disagreed with. You have presented cardiac tamponade as akin to AAA, which is not the case. Bedside emergency pericardiocentesis is performed in extreme situations. The common sequence of events in cardiac tamponade is physical examination > echocardiograhy and pericardiocentesis > right-sided catheterization (if appropriate)

I've looked this up in Cecil (23/e) as well, and it's written that "For patients in whom the history or physical examination suggests tamponade, emergency transthoracic echocardiography is imperative and generally diagnostic."

I guess the main problem at hand here is the cardiovascular stability of the patient. Obviously, an emergency bedside pericardiocentesis (among with other things) is necessary in a patient with BP of 60/30 mm Hg with no pulse, but this is not a common presentation of cardiac tamponade. In fact, many patients with cardiac tamponade do not present with hypotension.

I'm not sure how I've presented Cardiac Tamponade as an AAA. Could you elaborate on that? That statement legitimately confused me.

I do agree with you in the last paragraph. If the patient is stable enough, a transthoracic echo sounds like a right move. But I've yet to see a Tamponade patient presented on the USMLE (or any of its resources) that I'd call stable. And that's just because hypotension is part of the "classic" presentation of Tamponade.

 

[Fuzuli]

What if the question states each as an option, which one would you go for?

I would say Echo., so you can r/o constrictive pericarditis as well.

FYI, the ''answer key''; Dx: effusion, not tamponade.

There could be another clue in the patient history, but based on this information, I would choose echo as well.

Effusion and tamponade are not separate entities. Cardiac tamponade is a manifestation of pericardial effusion. However, presence of pulsus paradoxus and electrical alternans favors cardiac tamponade.

Harrison's 17/e, p.1490: "Otherwise unexplained enlargement of the cardiac silhouette (especially in subacute or chronic tamponade), reduction in amplitude of the QRS complexes, and electrical alternans of the P, QRS,
or T waves each should raise the suspicion of cardiac tamponade."

Evidence-Based Physical Diagnosis 2/e, p.513: "In patients with pericardial effusions, the finding of pulsus paradoxus greater than 12 mm Hg detects tamponade with a sensitivity of 98%, specificity of 83%, positive LR of 5.9, and negative LR of 0.03"

I'm not sure how I've presented Cardiac Tamponade as an AAA. Could you elaborate on that? That statement legitimately confused me.

Not as AAA, but akin AAA.

A 60 year old man with a 20 year history of HTN, 50 year-pack history of smoking and hyperlipidemia has a high risk of AAA. When such a patient presents with acute tearing epigastric pain, the likelihood of him having aortic dissection is very high. In many of such cases, such a patient would be rushed to the OR, without imaging. However, there are cases of AAA that presents with acute abdominal pain which could at first be managed medically and obtaining CT/MRI/TEE/etc. is possible.

Let's slightly modify this patient: This time, he has a known lung cancer and presents with shortness of breath. His physical examination shows pulsus paradoxus and engorged jugular veins. His EKG reveals electrical alternans [So basically he's like the patient in the original post] Based on this, he has a preliminary diagnosis of pericardial effusion.

So what would be a typical BP value in such a patient? Hypotension would be the incorrect choice, since cardiac tamponade can present with low, normal or even high blood pressure. In fact, most of the patients (%58-100) with cardiac tamponade would have systolic BP >100 mm Hg (Evidence-Based Physical Diagnosis, 2/e, p.513). So saying that patient with cardiac tamponade typically present with Beck's triad is not correct.

Let's move to my second point: Even if such a patient has hypotension, the decision to perform emergency bedside pericardiocentesis is not clear. Let's say the patient above has a BP of 90/60 mm Hg. Is this enough to peform a bedside pericardiocentesis, similar to patient being rolled to OR when dissecting AAA is suspected? I haven't found any literature to support this. Hypotension alone would not make someone hemodynamically unstable.

Ultimately, I don't think what we say very different. If a patient is unstable, an emergency bedside pericardiocentesis is warranted. If he's stable, then echocardiography and echo-guided pericardiocentesis is warranted. What we seem to disagree on what would make a cardiac tamponade patient "unstable", which I've talked about above.

Hope this makes it more clear.

 

[Golding]

Much more clear, thanks for the explanation.

I think your final paragraph also outlines where we agree well. So since we seem to disagree on what would be considered unstable, what would you say is unstable?

Personally, if I see a patient suggestive of Tamponade that has hypotension, heart failure, poor perfusion, I'd consider the person unstable

 

[kdburton]

If the question actually says what is the next step in MANAGEMENT then the answer isn't echo or pericardiocentesis, the answer is administration of IV fluids.

 

[yalemd]

That is the original question:

68 yo with Hx of small cell lung cancer went for surgery and chemoTx 3 yrs ago. He hasn't had a recurrence to date. Now presents with dyspnea, orthopnia and non productive cough, but no fever or chest pain. PE: Afebrile, Pulse: 100, BP: 90/48 RR:20. Pulsus Paradoxus 18. JVDs, clear lungs and distandheart tones. CXR: clear lung and cardiomegaly. EKG: electerical alternans is seen.

What is the next step in the management:

1: Echo
2: Pericardiocentesis
3: CT Chest
4: Broncoscopy

Well, we know 3 and 4 don't imply here. Though CT can detect effusion but it doesn't have the options of detecting heart wall motions (and thus r/o constrictive pericarditis) that Echo does.

the triad of tamponade presents, but the key answer Dx is Effusion and next step is echo.

For me I would consider such a patient is hemodynamically unstable, though it is unclear (cut-edge) tachy. but looking at such BP and RR that would make me choose #2.

Thanks to all of you who gave it a try.

 

[Fuzuli]

Much more clear, thanks for the explanation.

I think your final paragraph also outlines where we agree well. So since we seem to disagree on what would be considered unstable, what would you say is unstable?

Personally, if I see a patient suggestive of Tamponade that has hypotension, heart failure, poor perfusion, I'd consider the person unstable

I agree that a patient with heart failure, poor perfusion and hypotension should definitely be considered as unstable. For the purposes of the exam, I would look for signs of deteriorating hemodynamic parameters despite optimal medical therapy. For example: "Patient's BP has remained 90/60 mm Hg with a HR of 110/min despite treatment with inotropics and IV fluid resuscitation"
I don’t think there’s a universally agreed definition of hemodynamic instability though.

For me I would consider such a patient is hemodynamically unstable, though it is unclear (cut-edge) tachy. but looking at such BP and RR that would make me choose #2.

I would say both #1 and #2 has merits, but I would have expected another clue in the question stem about hemodynamic instability. In the absence of such clue, I would lean to #1.

If the question actually says what is the next step in MANAGEMENT then the answer isn't echo or pericardiocentesis, the answer is administration of IV fluids.

True, in fact if the patients BP and HR weren't improved by IV fluids (and inotropics), I would surely consider doing bedside pericardiocentesis.

 

[OveractiveBrain]

Hemodynamic Instability is has a test answer and a real world answer.

Test Answer:
Systolic Blood Pressure < 90mmHg
Chest Pain
Shortness of Breath
Altered Mental Status

Real Life Answer:
Whatever you are comfortable with. I knew a guy who would cardiovert every incidence of Vtach, regardless of presentation or vitals. Know how many times he was written up? Zero. Stability is really what you think this person will need in the next few minutes or hours; is there time to play, or is there time to die?

I agree so far with the thread. Unstable = Pericardiocentesis, stable = echo. Technically, the best radiographic test would be an MRI, but thats ridiculous and would detect teenie tiny effusions and pericarditis, and wouldn't be needed for a full-blown pericardial tamponade.

If the question read "elevated JVD, trachea midline, hypotension, shortness of breath but clear lungs" stick a needle in there.