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PERICARDIAL DISEASES FOR MBBS STUDENTS.pptx

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Smarakranjan Rout

PERICARDIAL DISEASES CARDIAC TAMPONADE CONSTRICTIVE PERICARDITIS FOR MBBS STUDENTS

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10/10/2024 1 Pericardial diseases Dr. Smarak Ranjan Rout DM, Cardiology Assistant Professor, AIIMS, Deoghar
10/10/2024 2 Overview Introduction- Normal Pericardium Acute pericarditis Constrictive pericarditis Pericardial effusion Cardiac tamponade
10/10/2024 3 Pericardium is the sac that surrounds the heart Made up of - outer fibrous pericardium - inner serous pericardium (parietal & visceral) Pericardial fluid : up to 50 ml of clear plasma ultra filtrate between the two layers of the serous pericardium The Normal Pericardium
10/10/2024 4 Functions 1.Stabilization of the heart within the thoracic cavity by virtue of its ligamentous attachments -- limiting the hearts motion. 2. Protection of the heart from mechanical trauma and infection from adjoining structures. 3. The pericardial fluid functions as a lubricant and decreases friction of cardiac surface during systole and diastole. 4. Prevention of excessive dilation of heart especially during sudden rise in intra-cardiac volume (e.g. acute aortic or mitral regurgitation).
10/10/2024 5 PERICARDIAL DISEASES
10/10/2024 6 Acute pericarditis
10/10/2024 7 Acute pericarditis Most common pathologic process involving the pericardium. Classification Of Pericarditis : Clinical Etiological
10/10/2024 8 Clinical classification
10/10/2024 9 Etiological classification T = Trauma, Tumour U = Uremia M = Myocardial infarction (acute, post) Medications (hydralazine) O = Other infections (viral,bacterial, fungal, TB) R = Rheumatoid, autoimmune disorder Radiation
10/10/2024 10 Clinical features- Symptoms Preceded by fever, malaise and myalgia Common characteristics of pain retrosternal or precordial with radiation to the trapezius ridge, neck, back, left shoulder or arm Special characteristics of pericardial pain more likely to be sharp with coughing, inspiration, swallowing worse by lying supine, relieved by sitting and leaning forward
10/10/2024 11 Clinical features- Signs Triphasic friction rub is pathognomonic; scratching or grating sound; evanescent Best heard in the lower LSB with the patient sitting and leaning forward Pericardial rub Pleural rub Can be heard even after cessation of breathing Can be heard only during inspiration and expiration Heard mostly over the sternum or sternal borders Heard mostly over the lateral parts of the chest Intensity doesnt increase with increased pressure of the steth Intensity of rub increases with increased pressure of the steth over the chest wall
10/10/2024 12 D/D- Pericarditis vs MI
10/10/2024 13 ECG CHANGES Pericarditis MI Early Repolarisation ST elevations Concave, Not restricted to arterial territory. return to normal within hours Convex Not restricted to arterial territory. return to normal within days Concave Not restricted to arterial territory. ; never return to normal ST depression (Reciprocal) in avR /V1 More prominent Not present PR segment depression present Not present Not present QRS changes No such changes Q waves, as well as notching and loss of R- wave amplitude) No such changes T-wave inversions after ST segment becomes isoelectric. usually seen within hours before the ST segments have become isoelectric. Not present; Tall T wave
10/10/2024 14
10/10/2024 15 MI ECG
10/10/2024 16 ERS ECG
10/10/2024 Acute Pericarditis Management Treat underlying cause Analgesic agents codeine 15-30 mg q 4-6 hrs Anti-inflammatory agents Aspirin NSAID (indomethacin 25-50 mg qid) Corticosteroids are symptomatically effective , but preferably avoided 17
10/10/2024 18 Pericarditis after AMI Early Occurs - 1 to 3 days (no more than a week due to transmural necrosis with pericardial inflammation 40% of patients with large, Q- wave MIs have pericarditis Benign aspirin doses (650 mg orally three or four times per day for 2 to 5 days) or acetaminophen is usually effective Late (Dressler's Syndrome) Occurs - 1 week to a few months after AMI . autoimmune etiology 3% to 4%. Polyserositis with pericardial or pleural effusions Aspirin , Colchicine . Prednisone, 40 to 60 mg /d with a 7- to 10-day taper(If not responding to treatment or for recurrent symptoms)
10/10/2024 19 Chronic Constrictive Pericarditis- (CCP)
10/10/2024 20 Etiology- CCP Idiopathic or viral 42 to 49 % Post cardiac surgery 11 to 37 % Post radiation therapy 9 to 31 % Connective tissue disorder 3 to 7 % Post infectious (tuberculous or purulent pericarditis) 3 to 6 % Miscellaneous causes (malignancy, trauma, drug-induced, asbestosis, sarcoidosis, uremic pericarditis) 1 to 10 %
10/10/2024 21 CCP -Pathophysiology
10/10/2024 22 CCP -Pathophysiology Consequence of impaired ventricular filling causes fatigue, muscle wasting, and weight loss 2. Reduced cardiac output : Hypotension/shock, Reflex tachycardia Riased JVP; Hepatic congestion, peripheral edema, ascites , anasarca, and cardiac cirrhosis. 1.Systemic > pulmonary venous congestion Pericardium Rigid and Scarred > Impaired Ventricular filling- mainly Early filling > ventricular interdependence
10/10/2024 23 Physical examination BP, HR JVP ascites, edema, hepatomegaly early diastolic knock after S2 sudden cessation of ventricular diastolic filling imposed by rigid pericardial sac Kussmauls sign inspiratory increase in JVP
10/10/2024 24 Kussmauls sign In Inspiration : Normal : RV Volume increases without increase in RA pressure. In Constrictive pericarditis : RV volume increases , as the RV cannot expand due to thickened pericardium ,this results in increase in RA pressure which causes Elevated JVP in inspiration.
10/10/2024 25 Evaluation/Investigation Clinical suspicion followed by confirmation with certain diagnostic tests ( many patients are initially seen for abdominal symptoms) ECG : AF in 1/3rd of patients flattened or inverted T waves
10/10/2024 26 Chest X ray Pericardial calcification
10/10/2024 27 Echocardiogram - pericardial thickening - septal bounce : abrupt displacement of IVS during early diastole - restrictive filling pattern - >25% increase in mitral E velocity during expiration compared with inspiration D/D- RCMP
10/10/2024 28 Confirmation is usually through CT / MRI
10/10/2024 29 Management Medical: Cautious diuretics and salt restriction Sinus tachycardia is a compensatory mechanism, BB and CCB that slow the HR should be avoided. In patients with AF with FVR , digoxin is recommended as initial treatment to slow the ventricular rate before resorting to beta blockers or calcium antagonists. In general, the rate should not be allowed to drop 80 -90 / min Definitive treatment : Surgical pericardiectomy
10/10/2024 30 Pericardial effusion
10/10/2024 31 Definition Excessive Accumulation of fluid between the visceral and parietal layers of serous pericardium Quantification- Trivial : 50 100 cc Small : 100 cc Moderate : 500 cc Large : 1000 cc
10/10/2024 32 Etiology Nature of Pericardial Fluid Serous Transudative CHF , Renal failure Suppurative Pyogenic infection Hemorrhagic occurs with any type of pericarditis especially with infections and malignancies Inciting factor 1. Inflammatory- from infection, immunologic process. 2. Traumatic- causing bleeding in pericardial space. 3. Physical- such as: a. increase in hydrostatic pressure e.g. congestive heart failure. b. increase in capillary permeability e.g. hypothyroidism c. decrease in plasma oncotic pressure e.g. cirrhosis. 4. Mechanical- Decreased drainage of pericardial fluid due to obstruction of thoracic duct as a result of malignancy or damage during surgery.
10/10/2024 33 Clinical features Usually asymptomatic Can have symptoms of compression - dyspnoea, dysphagia, hoarseness of voice, hiccup, nausea Signs : muffled heart sounds paradoxically reduced intensity of rub
10/10/2024 34 Chest x ray usually requires > 200 ml of fluid cannot distinguish between pericardial effusion and cardiomegaly
10/10/2024 35 Electrocardiogram Low voltage complexes
10/10/2024 36 Echocardiogram
10/10/2024 37 Management Depends on the etiology , presence of hemodynamic compromise and the volume of fluid. Medical- No role for diuretics Interventional- Pericardiocentesis is not always necessary. Pericardiocentesis if Malignancy or Purulent pericarditis is suspected Hemodynamic compromise present
10/10/2024 38 Cardiac tamponade
10/10/2024 39 What is Tamponade ? Accumulation of fluid in the pericardial space causing increase in pressure with subsequent cardiac compression. Pericardial pressures > intracardiac pressures
10/10/2024 40 Aetiology Most common causes : Malignancy Idiopathic pericarditis Renal failure Tuberculosis Bleeding following cardiac Sx and trauma- Hemopericardium
10/10/2024 41 Cardiac Tamponade - Pathophysiology Most critical point occurs when an effusion reduces the volume of the cardiac chambers such that cardiac output begins to decline Mainly by impeding right-sided heart filling, with much of the effect on the left side of the heart due to secondary under filling.
10/10/2024 42 Cardiac Tamponade -Pathophysiology
10/10/2024 43 Cardiac Tamponade - Pathophysiology A ) Modest amounts of rapidly accumulating fluid can have major effects on cardiac function. B) Large, slowly accumulating effusions are often well tolerated, presumably because of chronic changes in the pericardial pressure- volume relation described earlier.
10/10/2024 44 Cardiac Tamponade -- Pathophysiology Accumulation of fluid under high pressure: compresses cardiac chambers & impairs diastolic filling of both ventricles SV systemicvenous pressures CO Hypotension/shock JVP Reflex tachycardia hepatomegaly ascites peripheral edema
10/10/2024 45 Clinical features Symptoms acute : confusion / agitation Signs ( Becks triad) - hypotension - elevated JVP - muffled heart sounds Pulsus paradoxus : insp drop in SBP > 10 mmhg Pulsus paradoxus also seen in CP, COPD, asthma
10/10/2024 46 Pulsus Paradoxus- Explanation Inspiration> Increased RV filling> Raised IPP > leftward bulging of the IVS > RV compresses and reduces LV volume (Ventricular Interdependence) The normal inspiratory augmentation of RV volume causes an exaggerated reciprocal reduction in LV volume.
10/10/2024 47 Pulsus Paradoxus- Clinical Demonstration When severe, it may be detected by palpating weakness or disappearance of the arterial pulse during inspiration. Measured by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration) and the systolic pressure at which the Korotkoff sounds are heard with each beat, independent of respiratory phase Between these two pressures, the sounds are heard only intermittently (during expiration). SYNCHRONISED FROM RESPIROPHASIC TO CARDIOPHASIC
10/10/2024 48 ECG- ELECTRICAL ALTERNANS
10/10/2024 49 Chest x ray Cardiac shadow rounded ; Flask like appearance Lungs appear oligemic
10/10/2024 50 Echocardiogram RA collapse RV collapse
10/10/2024 51 Management Avoid diuretics Adequate preload INTERVENTIONAL- Pericardiocentesis Pericardial window Pericardiectomy in selected cases
10/10/2024 52 Take aways Symptoms may be non cardiac CP and PE will mimic right heart failure In any RHF symptoms, rule out pericardial disease Clinical suspicion is essential for diagnosis Correct diagnosis is imperative Potential for permanent cure
THANKS 10/10/2024 53

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PERICARDIAL DISEASES FOR MBBS STUDENTS.pptx

  • 1. 10/10/2024 1 Pericardial diseases Dr. Smarak Ranjan Rout DM, Cardiology Assistant Professor, AIIMS, Deoghar
  • 2. 10/10/2024 2 Overview Introduction- Normal Pericardium Acute pericarditis Constrictive pericarditis Pericardial effusion Cardiac tamponade
  • 3. 10/10/2024 3 Pericardium is the sac that surrounds the heart Made up of - outer fibrous pericardium - inner serous pericardium (parietal & visceral) Pericardial fluid : up to 50 ml of clear plasma ultra filtrate between the two layers of the serous pericardium The Normal Pericardium
  • 4. 10/10/2024 4 Functions 1.Stabilization of the heart within the thoracic cavity by virtue of its ligamentous attachments -- limiting the hearts motion. 2. Protection of the heart from mechanical trauma and infection from adjoining structures. 3. The pericardial fluid functions as a lubricant and decreases friction of cardiac surface during systole and diastole. 4. Prevention of excessive dilation of heart especially during sudden rise in intra-cardiac volume (e.g. acute aortic or mitral regurgitation).
  • 7. 10/10/2024 7 Acute pericarditis Most common pathologic process involving the pericardium. Classification Of Pericarditis : Clinical Etiological
  • 9. 10/10/2024 9 Etiological classification T = Trauma, Tumour U = Uremia M = Myocardial infarction (acute, post) Medications (hydralazine) O = Other infections (viral,bacterial, fungal, TB) R = Rheumatoid, autoimmune disorder Radiation
  • 10. 10/10/2024 10 Clinical features- Symptoms Preceded by fever, malaise and myalgia Common characteristics of pain retrosternal or precordial with radiation to the trapezius ridge, neck, back, left shoulder or arm Special characteristics of pericardial pain more likely to be sharp with coughing, inspiration, swallowing worse by lying supine, relieved by sitting and leaning forward
  • 11. 10/10/2024 11 Clinical features- Signs Triphasic friction rub is pathognomonic; scratching or grating sound; evanescent Best heard in the lower LSB with the patient sitting and leaning forward Pericardial rub Pleural rub Can be heard even after cessation of breathing Can be heard only during inspiration and expiration Heard mostly over the sternum or sternal borders Heard mostly over the lateral parts of the chest Intensity doesnt increase with increased pressure of the steth Intensity of rub increases with increased pressure of the steth over the chest wall
  • 13. 10/10/2024 13 ECG CHANGES Pericarditis MI Early Repolarisation ST elevations Concave, Not restricted to arterial territory. return to normal within hours Convex Not restricted to arterial territory. return to normal within days Concave Not restricted to arterial territory. ; never return to normal ST depression (Reciprocal) in avR /V1 More prominent Not present PR segment depression present Not present Not present QRS changes No such changes Q waves, as well as notching and loss of R- wave amplitude) No such changes T-wave inversions after ST segment becomes isoelectric. usually seen within hours before the ST segments have become isoelectric. Not present; Tall T wave
  • 17. 10/10/2024 Acute Pericarditis Management Treat underlying cause Analgesic agents codeine 15-30 mg q 4-6 hrs Anti-inflammatory agents Aspirin NSAID (indomethacin 25-50 mg qid) Corticosteroids are symptomatically effective , but preferably avoided 17
  • 18. 10/10/2024 18 Pericarditis after AMI Early Occurs - 1 to 3 days (no more than a week due to transmural necrosis with pericardial inflammation 40% of patients with large, Q- wave MIs have pericarditis Benign aspirin doses (650 mg orally three or four times per day for 2 to 5 days) or acetaminophen is usually effective Late (Dressler's Syndrome) Occurs - 1 week to a few months after AMI . autoimmune etiology 3% to 4%. Polyserositis with pericardial or pleural effusions Aspirin , Colchicine . Prednisone, 40 to 60 mg /d with a 7- to 10-day taper(If not responding to treatment or for recurrent symptoms)
  • 19. 10/10/2024 19 Chronic Constrictive Pericarditis- (CCP)
  • 20. 10/10/2024 20 Etiology- CCP Idiopathic or viral 42 to 49 % Post cardiac surgery 11 to 37 % Post radiation therapy 9 to 31 % Connective tissue disorder 3 to 7 % Post infectious (tuberculous or purulent pericarditis) 3 to 6 % Miscellaneous causes (malignancy, trauma, drug-induced, asbestosis, sarcoidosis, uremic pericarditis) 1 to 10 %
  • 22. 10/10/2024 22 CCP -Pathophysiology Consequence of impaired ventricular filling causes fatigue, muscle wasting, and weight loss 2. Reduced cardiac output : Hypotension/shock, Reflex tachycardia Riased JVP; Hepatic congestion, peripheral edema, ascites , anasarca, and cardiac cirrhosis. 1.Systemic > pulmonary venous congestion Pericardium Rigid and Scarred > Impaired Ventricular filling- mainly Early filling > ventricular interdependence
  • 23. 10/10/2024 23 Physical examination BP, HR JVP ascites, edema, hepatomegaly early diastolic knock after S2 sudden cessation of ventricular diastolic filling imposed by rigid pericardial sac Kussmauls sign inspiratory increase in JVP
  • 24. 10/10/2024 24 Kussmauls sign In Inspiration : Normal : RV Volume increases without increase in RA pressure. In Constrictive pericarditis : RV volume increases , as the RV cannot expand due to thickened pericardium ,this results in increase in RA pressure which causes Elevated JVP in inspiration.
  • 25. 10/10/2024 25 Evaluation/Investigation Clinical suspicion followed by confirmation with certain diagnostic tests ( many patients are initially seen for abdominal symptoms) ECG : AF in 1/3rd of patients flattened or inverted T waves
  • 26. 10/10/2024 26 Chest X ray Pericardial calcification
  • 27. 10/10/2024 27 Echocardiogram - pericardial thickening - septal bounce : abrupt displacement of IVS during early diastole - restrictive filling pattern - >25% increase in mitral E velocity during expiration compared with inspiration D/D- RCMP
  • 28. 10/10/2024 28 Confirmation is usually through CT / MRI
  • 29. 10/10/2024 29 Management Medical: Cautious diuretics and salt restriction Sinus tachycardia is a compensatory mechanism, BB and CCB that slow the HR should be avoided. In patients with AF with FVR , digoxin is recommended as initial treatment to slow the ventricular rate before resorting to beta blockers or calcium antagonists. In general, the rate should not be allowed to drop 80 -90 / min Definitive treatment : Surgical pericardiectomy
  • 31. 10/10/2024 31 Definition Excessive Accumulation of fluid between the visceral and parietal layers of serous pericardium Quantification- Trivial : 50 100 cc Small : 100 cc Moderate : 500 cc Large : 1000 cc
  • 32. 10/10/2024 32 Etiology Nature of Pericardial Fluid Serous Transudative CHF , Renal failure Suppurative Pyogenic infection Hemorrhagic occurs with any type of pericarditis especially with infections and malignancies Inciting factor 1. Inflammatory- from infection, immunologic process. 2. Traumatic- causing bleeding in pericardial space. 3. Physical- such as: a. increase in hydrostatic pressure e.g. congestive heart failure. b. increase in capillary permeability e.g. hypothyroidism c. decrease in plasma oncotic pressure e.g. cirrhosis. 4. Mechanical- Decreased drainage of pericardial fluid due to obstruction of thoracic duct as a result of malignancy or damage during surgery.
  • 33. 10/10/2024 33 Clinical features Usually asymptomatic Can have symptoms of compression - dyspnoea, dysphagia, hoarseness of voice, hiccup, nausea Signs : muffled heart sounds paradoxically reduced intensity of rub
  • 34. 10/10/2024 34 Chest x ray usually requires > 200 ml of fluid cannot distinguish between pericardial effusion and cardiomegaly
  • 37. 10/10/2024 37 Management Depends on the etiology , presence of hemodynamic compromise and the volume of fluid. Medical- No role for diuretics Interventional- Pericardiocentesis is not always necessary. Pericardiocentesis if Malignancy or Purulent pericarditis is suspected Hemodynamic compromise present
  • 39. 10/10/2024 39 What is Tamponade ? Accumulation of fluid in the pericardial space causing increase in pressure with subsequent cardiac compression. Pericardial pressures > intracardiac pressures
  • 40. 10/10/2024 40 Aetiology Most common causes : Malignancy Idiopathic pericarditis Renal failure Tuberculosis Bleeding following cardiac Sx and trauma- Hemopericardium
  • 41. 10/10/2024 41 Cardiac Tamponade - Pathophysiology Most critical point occurs when an effusion reduces the volume of the cardiac chambers such that cardiac output begins to decline Mainly by impeding right-sided heart filling, with much of the effect on the left side of the heart due to secondary under filling.
  • 43. 10/10/2024 43 Cardiac Tamponade - Pathophysiology A ) Modest amounts of rapidly accumulating fluid can have major effects on cardiac function. B) Large, slowly accumulating effusions are often well tolerated, presumably because of chronic changes in the pericardial pressure- volume relation described earlier.
  • 44. 10/10/2024 44 Cardiac Tamponade -- Pathophysiology Accumulation of fluid under high pressure: compresses cardiac chambers & impairs diastolic filling of both ventricles SV systemicvenous pressures CO Hypotension/shock JVP Reflex tachycardia hepatomegaly ascites peripheral edema
  • 45. 10/10/2024 45 Clinical features Symptoms acute : confusion / agitation Signs ( Becks triad) - hypotension - elevated JVP - muffled heart sounds Pulsus paradoxus : insp drop in SBP > 10 mmhg Pulsus paradoxus also seen in CP, COPD, asthma
  • 46. 10/10/2024 46 Pulsus Paradoxus- Explanation Inspiration> Increased RV filling> Raised IPP > leftward bulging of the IVS > RV compresses and reduces LV volume (Ventricular Interdependence) The normal inspiratory augmentation of RV volume causes an exaggerated reciprocal reduction in LV volume.
  • 47. 10/10/2024 47 Pulsus Paradoxus- Clinical Demonstration When severe, it may be detected by palpating weakness or disappearance of the arterial pulse during inspiration. Measured by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration) and the systolic pressure at which the Korotkoff sounds are heard with each beat, independent of respiratory phase Between these two pressures, the sounds are heard only intermittently (during expiration). SYNCHRONISED FROM RESPIROPHASIC TO CARDIOPHASIC
  • 49. 10/10/2024 49 Chest x ray Cardiac shadow rounded ; Flask like appearance Lungs appear oligemic
  • 51. 10/10/2024 51 Management Avoid diuretics Adequate preload INTERVENTIONAL- Pericardiocentesis Pericardial window Pericardiectomy in selected cases
  • 52. 10/10/2024 52 Take aways Symptoms may be non cardiac CP and PE will mimic right heart failure In any RHF symptoms, rule out pericardial disease Clinical suspicion is essential for diagnosis Correct diagnosis is imperative Potential for permanent cure

Editor's Notes

  1. we will discuss todays topic under the following headings
  2. To outline the pericardial anatomy- Read Pictorial presentation of pericardium
  3. Coming to functions..- read highlighted parts
  4. We can broadly categorise the PERICARDIAL DISEASES into two subtypes; we will briefly summarize each of these disease entities in the subsequent slides
  5. Lets start with Acute pericarditis
  6. Read
  7. From a clinical point of view , pericarditis can be--
  8. Etiologically , mnemonic can be remembered
  9. Ac Pericarditis clinically presents with a viral prodrome like picture with characteristics pain--
  10. A specific clinical sign is pericardial rub which is pathognomonic- Atrial systole, ventricular systole, Ventricular diastole- protodiastole; Read--
  11. A close d/d is MI; Any symptoms can be described by acronym- DSO PRCA. Read
  12. Do you have a basic idea of ECG? ECG changes are quite interesting and a target for your NEET PG MCQs; Intervals and waves
  13. READ FOOTNOTE
  14. Mark reciprocal STD;
  15. Mark here no T wave inversion;
  16. Read; For symptomatic relieve---
  17. Just to mention a keynote regarding Pericarditis after AMI; read highlighted parts
  18. Now lets discuss the second disease entity
  19. Maximum cases are idiopathic, in India still TB a very common cause; data taken from western literature
  20. The basic of haemodynamic consequences is mechanical factor. Pericardium Rigid and Scarred ; Explain negative pressure/suction ; Systolic contraction normal; Inhibits diastolic filling of both ventricles- But one at the expense of other one- ventricular interdependence
  21. Read; Why systemic congestion more ? As during inspiration because of negative suction its RV which gets more blood that too compromising its LV counter part.
  22. Read
  23. A potent MCQ; read
  24. Read
  25. show
  26. read
  27. Just Show
  28. Read
  29. Coming to 3rd disease entity--
  30. Defined as..
  31. Can be enlisted as per nature..... And inciting.....; any fluid collection in body can be divided by this principle
  32. Read
  33. Read; associated finding in cxr like lung congestion will differenciate
  34. 5 mm in limb leads ; 10 mm in chest leads
  35. show
  36. read
  37. Now coming to 3rd topic
  38. Read- definition; mark increased pressure here unlike uncomplicated PE
  39. read
  40. Almost similar to CCP- There a rigid scarred pericardium, here same by pressurised fluid collection
  41. Here Intra Cardiac Pressures- Diastolic EDP if less than IPP then tamponade starts
  42. Read Modest amounts of rapidly vs Large, slowly accumulating
  43. Similar to CCP
  44. Read
  45. Read- stress on Ventricular Interdependence
  46. Explain by demonstration- bp and pulse simultaneous measurement
  47. Show, QRS amplitude difference due to cardiac swinging
  48. Read and show
  49. Read and show
  50. INTERVENTIONAL- vis pericardial effusion
  51. The THM is..