So the next specific cardiac disease that we should talk about is the assessment of pericardial disease.
Some patients with simply having pericarditis,
whether its viral or potentially in the setting of lupus or even sarcoid and various other etiologies,
particularly with viral pericarditis, they're going to have pain in their chest
and as I alluded to in the very beginning of this talk,
this is a person who may look like they're in distress
and they may feel more comfortable sitting upright.
So patient with pericarditis typically is sitting upright, leaning forward
because that takes some of the stress off pericardial sack.
In contrast, when they lie flat, they're more uncomfortable and don't like to be in that position.
So the three cardinal features on physical exam that we're going to be looking for, for pericarditis
and in particular, severe pericarditis with the pericardial effusion
and even tamponade are these features.
Number one, if there's a lot of blood or fluid, serous fluid in the pericardium, around the heart,
when I attempt to listen to the heart, it's going to be muffled.
I'm not going to be able to hear the heart valves crisply,
the way that they normally would, so we would describe in our physical exam
that the patient has muffled or diminished heart sounds.
I may try and make those heart sounds a bit louder
by having the patient lean forward to really
and try maximally bring about the heart sounds if they're otherwise are diminished.
In addition, while I'm doing that, I may find that the pericardial sack,
the visceral and parietal pleura, the visceral and parietal pericardium,
are scratching against one another and that's called a rub, a friction rub.
When people have pericarditis all that inflammation is causing those two materials,
those two membranes to rub one against one another
and the friction rub of pericarditis is notoriously evanescent,
it can come and go from one minute to the next,
but you would hear it down here at the left lower external boarder,
its relatively high in pitch and it sounds like sandpaper,
two pieces of sandpaper being rubbed over one another.
It's most often has two or even three phases to the sound of the murmur
or the sound of the friction rub, and that's basically where you're going to hear it.
The next thing is what's called Beck's Triad,
so and we've already actually talked about one feature of Beck's Triad.
When somebody has pericardial effusion with tamponade,
the first thing you'll have as part of Beck's Triad is diminished heart sound,
you just can't hear the heart as well.
The second thing you'll have is something called Kussmaul's sign
which is part of Beck's Triad and it's basically that when I take a look at his neck veins again,
tilt your head again for me, Shaun, because in tamponade,
when blood goes to the right side of the heart during inhalation,
when you inspire, that increase blood doesn't have any room,
the right atrium doesn't have any room to balloon out at all,
because the pericardium is compressing all four chambers of the heart,
so when the blood goes into the right atrium,
rather than the right atrium being able to expand
and accommodate that increased blood during inspiration,
what's happens instead is the intraventricular septum and the intra-atrial septum
push into the left-side of the heart, it's like the right side of the heart is the side
that it should take prominence,
it's taking that extra volume of blood and it's pushing the left side of the heart away.
As you can imagine, if you're pushing the left-side of the heart away,
that means that there's less blood going into the left ventricle into the left atrium
and so once cardiac output goes down, just during inspiration.
So there's this to and fro, between the respiratory cycles where during exhalation,
there's a relatively normal systolic blood pressure, but during inhalation, inspiration,
the right side of the heart crowds out the left ventricular outflow track
and the blood pressure actually can drop a bit.
So Beck's Triad is going to include: muffled heart sounds, hypotension,
and because the right side of the heart is accommodating
all these extra blood that has no room for it to go,
we're going to see those jugular veins going up during inhalation.
Remember I said before that usually,
when you're breathing in, the negative intrathoracic pressure is drawing blood towards the heart,
so your jugular vein pressure goes down.
But with a large pericardial effusion there's no room for all that extra blood in the heart
because the pericardium is crowding all four chambers,
so when that extra blood return goes to the heart, it has nowhere to go,
so it ends up leading to elevated neck veins during inhalation,
and that's called Kussmaul's sign and that's part of Beck's Triad.
All three of those features would support the diagnosis of pericardial effusion.
But the number one most important physical exam finding
that we can do to diagnose a pericardial effusion with tamponade is pulsus paradoxus.
In pulsus paradoxus, the physiology goes back to what we were just talking about,
where, if this -- all these blood going back to the right side of the heart
it's going to crowd out the left-side of the heart and compromise left ventricular outflow tract.
What happens, the paradox, the reason that the term pulsus paradoxus came about,
was that when Kussmaul, it was actually Dr. Kussmaul back in the 1800's
was listening to the heart and he could hear the mitral valve and tricuspid valve closing,
opening and closing, he knew that that was systole.
He could hear the heart here, he can even palpate it by feeling left ventricular contraction
at the point of maximal impulse, but out here in the radial artery
he was not feeling a pulse, and that's because during inspiration, during inhalation,
while the heart was pumping, the cardiac output was so compromised
he could not feel the systolic pressure all the way here,
all the way out here in the radial artery and so that was the paradox,
he was hearing sounds here, but not being able to feel it here.
That's in somebody who has severe tamponade
and we're going to do this test called pulsus paradoxus to try and detect more subtle manifestations
or a more subtle presentation of tamponade by looking at the systolic pressure
as it vacillates during the respiratory cycle.
So let's get our blood pressure cuff and do the pulsus paradoxus test.
So what I've done now is I've got my Doppler probe,
my handheld Doppler on his radial artery which allows me to kind of cheat
and be able to hear what's going on with his systolic pulsation audibly
or allow you guys to hear it audibly rather than me using my stethoscope.
So what I'd do now is inflate the cuff
and before I do that since I don't want to strangulate his arm
while we're having a conversation is I'm going to inflate the cuff
to just above where his pressure goes away then I'm going to lower it very slowly,
one milliliter of mercury at a time,
and what we'll find is that they'll be a point
where the Korotkoff sounds of his systolic pulse will come in,
but they'll only be there during one part of the respiratory cycle.
So there'll be four or five beats, and then they'll disappear,
and then there'll be four or five beats and then they'll disappear;
and that's the top of what we'll mark as our,
the point where the respiratory variation allows some pulsations to go through but not all.
And the person without pulsus paradoxus, the person without pericardial effusion,
without tamponade -- we can expect that, again, when you take a deep breath,
you've got more blood return to the right side of the heart,
there's a little bit of bowing into the left ventricle
so that's when your systolic pressure will be lowest,
and when you're exhaling, that's when your systolic pressure is a little bit higher
and that's when those beats are going to get through and get down to my probe.
So let's pay attention to respiratory cycle
and we're listening to his radial heart, radial pulsation here.
Down to 160, 150, 140, 138, 136, 135, 132, 130, hear that vacillation?
The oscillation there is the normal physiology during the respiratory cycle, or during exhalation,
they're going to be louder they're going to be getting through, whereas during inhalation,
if I go up just a little bit they're only there when he's exhaling and then they disappear.
If I go down a bit further down to 124, they are there throughout the cycle.
As I go down even further, the beats are essentially the same throughout the cycle.
So the point that I wanted to make here is that pulsus paradoxus
is actually completely normal physiology but only to a degree.
You shouldn't have a discrepancy between the top of systole,
when the respiratory cycle is really most apparent,
when you can only hear those beats during exhalation
and not during inhalation, and the bottom,
where they're there throughout the respiratory cycle.
The difference between those two areas
should never be more than 10 and to 12 milliliters of mercury.
A person with significant pericardial effusion and tamponade,
that gap could be 15, 20 milliliters of mercury in difference
between the top level and the bottom level,
so don't think of pulsus paradoxus as some bizarre, completely unusual manifestation of disease.
It instead is an exaggeration of normal physiology
because that right side of the heart is crowding out the left side of the heart
because there's just no room in the pericardial sac for the right atrium
and right ventricle to expand a little bit to accommodate that extra volume.
So those are all the classic features we would look for, for pericarditis
and we can now move on to our next cardiac condition.