Snapshot A 45-year-old woman presents to the emergency room for chest discomfort and shortness of breath for the past few hours. She has a past medical history of systemic lupus erythematosus. Physical exam reveals hypotension, muffled heart sounds, distended jugular veins, and positive pulsus paradoxus. An echocardiogram (ECG) reveals low voltages and electrical alternans. Imaging shows an enlarged cardiac silhouette on radiography. A team is consulted for an emergent pericardiocentesis. Introduction Clinical definition accumulation of fluid in the pericardial sac that restricts ventricular filling Epidemiology risk factors pericarditis malignancy uremia systemic lupus erythematosus malignancy tuberculosis penetrating trauma Etiology pericardial effusion hemorrhage into the pericardial sac iatrogenic Pathoanatomy pericardium the pericardium is an elastic sac that can stretch to accommodate normal cardiac volume expansion however, if stretched beyond normal physiological expansion, the pericardium will stiffen Pathogenesis cardiac tamponade increased pericardial pressure from the fluid accumulation causes compression of the cardiac chambers this results in decreased cardiac output and blood pressure pulsus paradoxus normally, inhalation increases venous return → expands the right ventricle in cardiac tamponade, the stiff pericardium will prevent the free wall from expanding the only area for the right ventricle to expand is the interventricular septum, which will compress the left ventricle compression of the left ventricle → decreased filling of the left heart → decreased blood pressure Associated conditions ruptured ascending aortic dissection ventricular free wall rupture from myocardial infarction Prognosis in acute cases, cardiac tamponade can develop rapidly in chronic cases, cardiac tamponade will develop gradually, as the pericardium can adjust slowly to the increased pressure over time Presentation Symptoms chest pain fatigability often unresponsive to fluid resuscitation Physical exam Beck triad muffled heart sounds jugular venous distention hypotension cardiac ↑ heart rate pericardial rub if the patient has an inflammatory pericarditis pulsus paradoxus a decrease in blood pressure > 10 mmHg during inhalation pulmonary shortness of breath lung fields are typically clear extremities cold and clammy peripheral cyanosis Imaging Echocardiography indications for diagnosis of cardiac tamponade most accurate test for all patients findings diastolic collapse of the right heart fluid in the pericardial space swinging of the heart within the effusion Radiography indication for all patients views chest findings enlarged cardiac silhouette seen only in subacute cardiac tamponade in acute cases, pericardium will not accommodate build up of > 200 cc of fluid, which is required to appear enlarged on radiography Studies Electrocardiogram (ECG) indications for all patients findings low voltage electrical alternans variations in the height of the QRS complex from swinging of the heart in the chest Right heart catheterization indication typically not performed as an initial test findings equilibration of pressures in all 4 chambers during diastole Making the diagnosis based on clinical presentation, ECG, echocardiogram, and chest radiography Differential Constrictive pericarditis distinguishing factors also has pulsus paradoxus, but also presents with Kussmaul sign increase (or absence of decline) in jugular venous pressure with inhalation pericardial knock Tension pneumothorax distinguishing factors decreased or absent breath sounds hyperresonant percussion Treatment Management approach all approaches focus on removal of the fluid in the pericardium Conservative close monitoring and volume expansion indication cardiac tamponade without hemodynamic compromise modalities serial echocardiographs intravenous bolus of fluids Procedural percutaneous pericardiocentesis indication first-line treatment Operative surgical drainage indications patients with coagulopathy or need for biopsy purulent pericarditis traumatic cardiac tamponade surgical drainage with pericardial window placement indication patients with chronic pericardial effusions patients who decompensate Complications Death
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.CV.4685) A 45-year-old male is brought into the emergency room by emergency medical services due to a stab wound in the chest. The wound is located superior and medial to the left nipple. Upon entry, the patient appears alert and is conversational, but soon becomes confused and loses consciousness. The patient's blood pressure is 80/40 mmHg, pulse 110/min, respirations 26/min, and temperature 97.0 deg F (36.1 deg C). On exam, the patient has distended neck veins with distant heart sounds. What is the next best step to increase this patient's survival? Review Topic QID: 107358 Type & Select Correct Answer 1 Intravenous fluids 0% (0/2) 2 Intravenous colloids 0% (0/2) 3 Heparin 0% (0/2) 4 Aspirin 0% (0/2) 5 Pericardiocentesis 100% (2/2) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 5 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.CV.4689) A 36-year-old female with a history of end stage renal disease secondary to poorly controlled type I diabetes on peritoneal dialysis presents to her nephrologist's office with chest pain, shortness of breath, and extreme fatigue. She has a history of inadequate dialysis due to poor compliance. In the office, the patient's vitals are BP: 94/58; HR: 90; RR: 20; T: 98.0 F. EKG is shown below (Figure A). The patient is immediately taken to the emergency department. What is the most likely diagnosis? Review Topic QID: 107519 FIGURES: A Type & Select Correct Answer 1 Pericardial effusion 100% (2/2) 2 ST elevation MI 0% (0/2) 3 Non-ST elevation MI 0% (0/2) 4 Hyperkalemia 0% (0/2) 5 Pericarditis 0% (0/2) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 1 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.CV.4045) A 36-year-old male is brought to the ED by fire-rescue after falling off a third-story scaffolding onto his back. On exam, HR is 126 bpm, BP is 80/56 mmHg, RR is 24 bpm, and temperature is 99.0 degrees Fahrenheit. Glascow Coma Score is 8, jugular veins are distended, and heart sounds are distant. Chest radiograph (Figure A) is shown. All of the following treatments may improve the patient's blood pressure EXCEPT: Review Topic QID: 107017 FIGURES: A Type & Select Correct Answer 1 Catheter pericardiocentesis 11% (2/19) 2 Aggressive volume expansion 32% (6/19) 3 Positive pressure mechanical ventilation 21% (4/19) 4 Urgent surgical exploration 26% (5/19) 5 Placement of a pericardial window 5% (1/19) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.CV.39) A 23-year-old female with a history of systemic lupus erythematous presents with 1 week of chest pain and shortness of breath. Exam is notable for increased respiratory rate, mild hypotension, and muffled heart sounds. Chest radiography is performed and the results are seen in figure F. Which of the following electrocardiograms would you expect to see in this patient? Review Topic QID: 104045 FIGURES: A B C D E F Type & Select Correct Answer 1 Figure A 58% (11/19) 2 Figure B 21% (4/19) 3 Figure C 5% (1/19) 4 Figure D 0% (0/19) 5 Figure E 5% (1/19) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 1