CURRENT Essentials of Critical Care.pdf

120 Current Essentials of Critical Care■■■Cardiac TamponadeEssentials of Diagnosis• Beck triad: hypotension, elevated jugular venous pressure (JVP),muffled heart sounds• Pleuritic chest pain, dyspnea, orthopnea, palpitations, oliguria• Tachycardia, pericardial rub, pulsus paradoxus, peripheraledema, distended neck veins• Kussmaul sign: increased JVP with inspiration; nonspecific• Chest radiograph may not show enlarged cardiac silhouette (water-bottleshaped heart) if acute onset• ECG with reduced voltages, electrical alternans• Echocardiogram with pericardial effusion, “swinging heart,”right atrial systolic or ventricular diastolic collapse• Pulmonary artery catheterization with equalization of pressures:right atrial, left atrial, left ventricular end-diastolic• Pericardial effusion compromises ventricular filling with reducedcardiac output• Etiologies: uremia, pericarditis, malignancy, infection (viral,bacterial, fungal, tuberculosis), myocardial infarction/rupture,trauma, idiopathic, hypothyroidism, anticoagulation (especiallypost–cardiac surgery)Differential Diagnosis• Constrictive pericarditis • Restrictive cardiomyopathy• Tension pneumothorax • End-stage cardiac failure• Right ventricular infarctionTreatment• Volume resuscitation for hypotension; dopamine if blood pressuredoes not improve with fluids• Pericardiocentesis with or without pigtail catheter drainage• Hemodynamic monitoring with pulmonary artery catheter• Treat underlying cause of pericardial effusion• Surgical pericardial window (pericardiectomy or balloon pericardiotomy)if recurrent accumulation• Positive pressure ventilation may worsen symptoms■ PearlThe “rule of 20s” in cardiac tamponade: CVP 20 mm Hg, HR increase20 beats per minute, pulsus paradoxus 20, systolic BP, decrease20 mm Hg, and pulse pressure 20.ReferenceSpodick DH: Acute cardiac tamponade. N Engl J Med 2003;349:684. [PMID:12917306]