CPC

1
CPC 4

• Edward K. Kasper, M.D.
• Chief of Clinical Cardiology
• Johns Hopkins Hospital

2
A 60 year-old female

• Multiple risk factors for coronary artery disease
  on dialysis
• Presents with hypoglycemia
• Elevated troponin ASA, heparin, BB, TNG
• Probable UTI - gatifloxacin
• Large pericardial effusion
• Asystolic cardiac arrest and dies

3
Timeline of Events

• 12/10 ED, hyperkalemia, Hct 44, started on
  gatifloxacin
• 12/11 Medicine, BB, ASA, Heparin, nitrates,
  dialyzed, Hct 35
• 12/12 Dialysis, echo - large pericardial
  effusion, no tamponade
• 12/13 Water bottle heart on CXR, asystolic at 5
  AM

4
JAMA April 25, 2007
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Causes of Pericardial Effusion

• Idiopathic
• Infection (bacterial, viral, retroviral, fungal,
  parasitic, TB)
• Trauma
• Hemorrhage (trauma, MI, Aortic rupture, heart
  surgery)

• Cancer
• Radiation therapy
• Kidney failure
• Autoimmune disorders (SLE, RA)
• Hypothyroidism
• Drugs (PCN, anticoagulants)

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Tamponade
Tamponade
Normal
20
3
10
X
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Tamponade - Clinical Findings

• They look sick!
• Tachypnea
• Pale
• Diaphoresis
• Cool extremities
• Cyanosis

• Confusion
• Hypotension
• Paradoxical pulse
• Elevated JVP
• Tachycardia

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Cardiac Arrest

• CAD
• Cardiomyopathy
• Myocarditis
• Commotio cortis
• Tamponade
• Embolism
• Pneumothorax
• Hypovolemia

• Hypoxia
• Potassium (high, low)
• Calcium (high)
• Catecholamines
• Hypothermia
• Long QT
• Electrocution
• Drowning

9
Drug-Induced Long QT Syndrome

• Possible gatifloxacin
• www.arizonacert.org

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Possible Hypotheses

• Silent myocardial infarction leading to cardiac
  rupture into pericardial space
• Aortic rupture into pericardial space
• Pericarditis (uremic) with heparin-induced
  bleeding into pericardium
• Primary arrhythmic event

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Correct Me If Im Wrong!