Title of Case: Etiology and treatment of pericardial tamponade.
Background: While in the SICU, I was involved in the care of a patient that presented with pericardial tamponade. He subsequently underwent a pericardiocentesis and a pericardial window. I was interested in the specific causes of pericardial effusions/tamponade as well as the incidence of each cause. Furthermore, I was interested in the treatment of cardiac tamponade. Specifically deciding between pericardiocentesis versus pericardial window.
Case presentation:
HPI: 45-year-old male with past medical history of hypercholesterolemia and hypertension who presented with chest pain. Patient had been moving furniture with his wife all morning. After some time he developed chest
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pain that radiated through to his back and down his arm. He went on to become lethargic and had a syncopal episode. On the way to the hospital he had a seizure. He arrived at the hospital in cardiogenic shock. • PMH: hypercholesterolemia, hypertension • PSH: shoulder surgery and cervical fusions • Allergies: NKDA • Medications: lisinopril, hydrochlorothiazide, omeprazole • Physical exam: Obese male, lethargic, tachycardic, pulses at time of assessment were 1+ weak and thread • Abnormal labs: Potassium 3.0, Glucose 146, BUN 21, Creatinine 1.23, WBC 14.3 • CT head: no evidence of acute intracranial process • CTA of chest and abdomen at time of admission: no aortic dissection, moderate circumferential pericardial effusion that appears hyperdense, measuring 35-40 Housfield units on precontrast images and appears to have significant enhancement.
SVC appeared normal
Patient Management:
He immediately had a stat CTA performed and was found to have a pericardial effusion. A pericardiocentesis was then attempted yielding a minimal amount of bright red blood. Patient then proceeded to code in the ER and was revived. It was then decided to take the patient to the OR to perform pericardial window. The pericardial window yielded 300ml of blood. Following the pericardial window he remained in critical condition in SICU.
Following this presentation he underwent a workup for the possible etiology of the pericardial effusion including pericardial fluid pathological analysis and culture, pericardial tissue pathological analysis, thyroid function tests, HIV and TB tests, and a rheumatic
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workup. Differential Diagnosis: cardiogenic shock. 1. Acute MI 2. Aortic dissection 3. Massive pulmonary embolism 4. Arrythmia including bradyarrythmia or ventricular tachyarrythmia 5. Pericardial Tamponade 6. Septic shock with myocardial depression 7. Severe myocarditis 8. Tension pneumothorax Causes of pericardial disease/effusion 1. Idiopathic 2. Infections (coxsackievirus, echovirus, adenovirus, bacterial) 3. Neoplasm (lung, breast, hodgkins disease, leukemia) 4. Autoimmune (lupus, RA, vasculitis) 5. Hypothyroidism 6. Cardiac (Dressler’s syndrome, myocarditis, aortic aneurysm) 7. Trauma to the chest 8. Drugs (procainamide, isoniazid) 9. Uremia 10. Radiation Outcome: The patient was hypotensive the night following admission and required IV fluids and pressors. The patient’s course in the ICU was complicated by his recovery from the cardiogenic shock with possibly a component of septic shock and acute kidney injury. Furthermore, he suffered from a component of ventilator dependent respiratory failure and possibly mild ARDS. His hemodynamic status stabilized one to two days following the pericardial window. However, he remained on AC and SIMV ventilation for several days with intermittent episodes of bucking the vent requiring respiratory stabilization with a muscle relaxant. After handling a course of PSV the patient was weaned and extubated on post-op day 6. The specific etiology of the pericardial effusion had not been discerned by the time he was discharged from the ICU. Discussion: etiology of pericarditis, pericardial effusion and pericardial tamponade and treatment of pericardial tamponade. Several studies have looked into the etiology of moderate to large pericardial effusions. In the US, a study from 1993 of 57 patients with new unexplained pericardial effusion found the top 3 etiologies to be malignancy (23%), infection (27%) and radiation (14%) while a 2003 study from France of 204 patients found the top three etiologies to be idiopathic (48%), infection (16%) and malignancy (15%). In the US study pericardial fluid led to the diagnosis in 26% of cases and pericardial tissue led to the diagnosis in 23% of cases (Corey; Levy). Regarding only hemorrhagic infusion leading to pericardial tamponade with need for pericardiocentesis, a study from the US looking at 96 cases found the etiology to be: malignancy in 26% of cases, procedure related 18%, post pericardiotomy syndrome 13%, complication of MI 11%, idiopathic 10%, uremic 7%, aortic dissection 4%, trauma 3% (Atar). Pericardiocentesis is usually the treatment of choice for pericardial tamponade as it can be performed outside the operating room and thus can be performed more rapidly and at a lower cost.
Benefits of a pericardial window include the ability to take diagnostic biopsies as well as to perform pericardiectomy if needed. Surgical exploration is also useful for cases that involve fluid reaccumulation and loculated fluid. In terms of traumatic cases a pericardial window may be more preferred especially in cases of aortic dissection or myocardial rupture. One study looked at 100 patients presenting with cardiac tamponade at a single center. Of the patients, 38% received pericardiocentesis only, 26% received surgical treatment only and 26% received pericardiocentesis followed by surgical treatment. Complication rates and mortality rates were highest in the two surgical groups leading the authors to conclude that pericardiocentesis should be performed first in idiopathic cases and in patients with hemodynamic instability. However, they further concluded that surgery may be the best approach for trauma and those with recurrent effusions where mortality rates may be higher
(Gumrukcuoglu). Learning points/take home messages: Malignancy and infection as possibly etiologies must be highly considered in all forms of pericardial effusions while hemorrhagic effusions are much more likely to be procedure and trauma related. The study of pericardial fluid leads to the diagnosis in a significant amount of cases (26%) but pericardial tissue can also help with the diagnosis (23%) and represents an advantage of performing a cardiac window. Finally, pericardiocentesis is the treatment of choice for most presentations of cardiac tamponade however early surgical treatment should be considered in cases of trauma. References: Corey GR, Campbell PT, Van Trigt P, et al. Etiology of large pericardial effusions. Am J Med 1993; 95:209. Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore) 2003; 82:385. Atar S, Chiu J, Forrester JS, Siegel RJ. Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s? Chest 1999; 116:1564. Gumrukcuoglu HA, Odabasi D, Akdag S, Ekim H. Management of Cardiac Tamponade: A Comperative Study between Echo-Guided Pericardiocentesis and Surgery-A Report of 100 Patients. Cardiol Res Pract 2011; 2011:197838.
759. Mr. Miller is likely presenting with an acute myocardial infarction. Based on his past medical history of hypertension, hyperlipidemia, obesity, and diabetes, along with his current symptoms of chest pain, shortness of breath, pale skin with beads of sweat on the forehead, as well as elevated lab 's Troponin, CK, and CK-MB, he is most likely presenting with an acute myocardial infarction.
According to the doctor, the patient might have developed congestive heart failure. Is it right-sided or
During my second pediatric residency at Woodhull hospital I did two-month rotations in pediatric cardiology in which I was directly involved in taking care of wide variety of congenital heart disease and to attend diagnostic and interventional cardiac catheterization cases, my interest in pediatric cardiology was further strengthened. My experience to pediatric cardiology field back home as well as in USA further intensify my insistence to pursue training in pediatric cardiology and eventually in interventional congenital cardiology. Being able to treat complicated lesions via transcatheter approach, sparing patients from having major cardiac surgery is indeed a revolution in patient care which I
R/o PE Heparin drip started. Venous Doppler studied report negative and chest x-ray obtained report no change from previous study no CTA 2nd to renal function
The Burden of the disease is high with a prevalence of 3.4% 2. With the progressive nature of the disease and the increased severity of the symptoms made the surgery the gold standard for symptomatic AS patients ,however up to 30% of cases are considered too high risk for classical valve replacement surgery and remain untreated and experiencing poor prognosis . Fortunately , with the introduction of TAVR its offer a valuable option for the inoperable or at high risk of surgery patients3..the annual eligible candidate for this procedure expected to be 27,000 in 19 European countries and North America according to recent meta-analysis an...
Client Profile: Lane Bronson is a 55 year old male with a history of angina, hypertension, Type 2 diabetes, COPD, and sleep apnea. He comes to the physican’s office complaining of worsening shortness of breath. His skin tone is grey, and his angina is worsening. Previously stable, he now does not get relief from rest or nitroglycerin. The physician called 911 and had Mr. Bronson directly admitted to the hospital.
...ts, electrocardiogram, sonogram and cardiac rehabilitation. As a clinical observer, I found an opportunity to create a solid foundation on patient diagnosis and treatment, and not to mention, long hours with charting and recording patients’ information.
Cardiovascular disease has become an increasingly significant issue in many countries as it is the leading cause of death for the whole human population. According to World Health Organization, ischemic heart disease had caused about 7 million people to lose their life in 2011. One of the most common cardiovascular illnesses is myocardial infarction. It is defined as the death of cardiac myocytes due to complete blockage of a coronary artery. t-PA is a thrombolytic drug that used to treat myocardial infarction by dissolving the thrombus that causes the occlusion.
On admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings. J.P. was positive for dyspnea and a productive cough. She also was positive for dysuria and hematuria, but negative for flank pain. After close examination of her integumentary and musculoskeletal system, the examiner discovered a shiny firm shin on the right lower extremity with +2 edema complemented by severe pain. A set of baseline vitals were also performed revealing a blood pressure of 124/80, pulse of 87 beats per minute, oxygen saturation of 99%, temperature of 97.3 degrees Fahrenheit, and respiration of 12 breaths per minute. The blood and metabolic panel exposed several abnormal labs. A red blood cell count of 3.99, white blood cell count of 22.5, hemoglobin of 10.9, hematocrit of 33.7%, sodium level of 13, potassium level of 3.1, carbon dioxide level of 10, creatinine level of 3.24, glucose level of 200, and a BUN level of 33 were the abnormal labs.
Some of the daily preparations that are performed by a perfusionist would consist of reading through a patient’s records to check out the patients history, family history, laboratory tests, cardiology reports and so on. Following this the heart and lung machine needs to be inspected and tested to make sure that it is in proper working order and that the disposables that are used are properly loaded and functional. Next the perfusionist needs to discuss with the surgeon what the needs of the patient may be and also what the needs of the surgeon may be. The perfusionist does this in order to use the correct disposables and correct pump to meet both the demands of the patient and that of the surgeon.
Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for " atypical chest pain and hemoptysis". V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit.
left ventricular function and heart failure.” Clinical Investigative Medicine. 31.2 (2008): E90-E97. Web. 15 Feb. 2014.
Look, I didn’t want to tell you this story. If you are afraid of germs, grossed out by toilets, or have any sense of personal hygiene I suggest you quit reading now. Believe that this is a disgusting horrifying terrible experience and move on to happier things because if you continue reading this you will most likely experience nausea, queasiness, and an overall feeling of absolute and horrible sickness. I’m sorry, your insides will be outside.
Which essential questions will you ask a pediatric patient or their caregiver when the presenting complaint is bloody diarrhea? Will these questions vary depending upon the child's age? Why or why not?
The patient has high temperature-sign of fever, a very fast pulse rate (tachycardia), and chest wheezing when listened to using a stethoscope (Harries, Maher, & Graham, 2004, p.