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Common Congenital Heart Lesions - page 73 / 126

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  • If sudden increase of volume results in big elevation of pericardial pressure and potential for severe cardiac chamber compression (even more so if pericardium is even less compliant than normal… like in presence of tumor or fibrosis of sac)

  • If slow accumulation of volume (like over weeks to months), the pericardium gradually stretches so that with adaptation, it can accommodate even up to 1-2 liters (!!!) of fluid w/out raising the pressure much

PRESENTATION

  • Spectrum from asymptomatic to cardiac tamponade

  • Symptoms of compression:

    • o

      Dysphagia (difficulty in swallowing)

      • o

        Dyspnea (pushing on the lungs)

      • o

        Hoarseness (recurrent laryngeal nerve compression)

      • o

        Hiccups (phrenic nerve stimulation)

PHYSICAL EXAM

  • Muffled heart sounds b/c large pericardial fluid insulates heart

  • Reduced intensity of friction rub if volume is large enough to have separated the 2

inflamed layers completely

  • Ewart’s sign Æ dullness to percussion of the left lung over the angle of the scapula

TEST and IMAGING

  • Chest x-ray Æ normal if small effusion. W/ more than 250 mL, cardiac silhouette enlarges in globular symmetric fashion.

  • ECG Æ reduced voltage of complexes… w/ really large effusions, height of QRS may vary from beat to beat (electrical alternans) b/c it’s like the heart is swinging side-to- side in a big water balloon, so electrical axis is always changing.

  • Echocardiography Æ most useful. Identifies volumes as small as 20 mL… can quantify volume, determine whether ventricular filling is compromised and help guide placement of a pericardiocentesis needle.

TREATMENT

  • If cause of effusion is known, get rid of cause

  • If cause is unknown, clinical state determines whether or not to do a pericardiocentises

  • If asymptomatic, even large volume could be observed for years…

  • But if there is a sudden rise in pericardial volume or cardiac compression is seen, then do

a pericardiocentises (drain the pericardium).

Cardiac Tamponade

This is just a really really bad pericardial effusion. The fluid accumulates under high pressure and smooshes the cardiac chambers so that cardiac filling is limited giving rise to low SV and CO and hypotension… hypotensive shock… and … death. (I told you it’s bad).

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