Cardiac Tamponade

Case Presentation:

In our Morning Report at WCH, we discussed a case of a patient presenting with new-onset exertional dyspnea and low voltage QRS complexes on ECG. Echocardiography revealed a large malignancy-related pericardial effusion and evidence of cardiac camponade.

Learning Points:

  1. A visual approach to dyspnea
  2. Wells PE Criteria memory aid
  3. Causes of elevated D-dimer
  4. Causes of low voltages on ECG
  5. Clinical features and investigation findings of pericardial effusion/tamponade
  6. Principles of Management

Dyspnea Image-Based Approach:

Approach to dyspnea.png

Wells PE Criteria:
wells-pe-score

  • The best memory tool I’ve come across for the Wells PE criteria is indicated above
  • Use these criteria to determine PE probability
  • Scores of <2 indicate low probability; D-dimer prior to additional imaging may be helpful at ruling out VTE in this setting

Elevated D-Dimer:

  1. Arterial occlusion/problem (MIA, CVA, limb ischemia, dissection)
  2. Venous occlusion (DVT, PE)
  3. Systemic disease (Malignancy, Infection/sepsis/DIC, trauma/surgery, pregnancy complications)

Low Voltages on ECG:

low-voltage-on-ecg

Features of Cardiac Tamponade:

features-of-tamponade

Principles of Management:

  • Hemodynamic effects warrant urgent intervention
  • Temporize with IV fluids to help maintain RV patency
  • Ultimately, transfer to an intensive care setting and pericardiocentesis is the definitive management
  • Identify & treat cause:
    1. 3 most common causes of moderate-large pericardial effusions: idiopathic, iatrogenic, malignant

Additional Reading:

  1. Roy, CL; Minor, MA; Brookhart, A; Choudhry, N. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA. 2007;297(16):1810-1818. doi:10.1001/jama.297.16.1810.

 

 

 

 

 

 

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