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Cardiac tamponade

Muhammad Aprianto Ramadhan


Stase Bedah
FK UGM/RSST Klaten
Anatomy
The pericardium, which
is the membrane
surrounding the heart,
is composed of 2 layers.
The thicker parietal
pericardium is the outer
fibrous layer; the
thinner visceral
pericardium is the inner
serous layer.
The pericardial space
normally contains 20-
50mL of fluid.
Whats happening in a cardiac
tamponade?
An increase in intrapericardial pressure and volume by 60 to 100 mL of blood and
clots in the pericardium
Disrupt ventricular filling stroke volume cardiac output SHOCK
LIFE THREATENING
BP , pulse pressure , CVP (except there is hypovolemia)
Compensatory mechanisms
Heart rate and total peripheral resistance (to maintain adequate cardiac output and blood
pressure).
increase in venomotor tone of vena cava greater increase of CVP less effective
In a normotensive patient, the earliest response to pericardial tamponade is a
progressive increase in CVP to a level greater than 15 cm H
2
O.
An increasing CVP in a hypotensive patient indicates that the normal
compensatory responses are unable to maintain an adequate cardiac output.
A simultaneous decrease in the CVP and blood pressure, which can occur
precipitously and without warning, signals decompensation and imminent
cardiac arrest.
When to suspect cardiac tamponade?
History of penetrating trauma to the chest or upper
abdomen
Rarely in blunt trauma
Shock or ongoing hypotension without obvious blood loss
Unsuccessful rescuscitation effort
Classic signs: Becks triad
Jugular venous distension
Hypotension
Muffled heart tone
Pulsus paradoxus
decrease in systolic pressure of >10 mmHg during inspiration
difficult to detect in rescuscitation practice

33%
patient
How to confirm cardiac tamponade?
Ultrasonography 98.1% sensitivity, 99.9% specificity
for pericardial effusion.
Tamponade: simultaneous presence of pericardial fluid
and diastolic collapse of the right ventricle or atrium
How to confirm cardiac tamponade?
Pericardial window
The most direct method to determine the presence of blood within
the pericardium.
Best performed in OR under GA through either the subxiphoid or
transdiaphragmatic approach.
Adequate equipment and personnel to rapidly decompress the
pericardium, explore the injury, and repair the heart should be
present.
Once the pericardium is opened and tamponade relieved,
hemodynamics usually improve dramatically and formal pericardial
exploration can ensue.
Exposure of the heart can be achieved by extending the incision to
a median sternotomy, performing a left anterior thoracotomy, or
performing bilateral anterior thoracotomies ("clamshell").

How to confirm cardiac tamponade?
Electrocardiography
Swinging heart phenomenon when
fluid accumulates to a critical extent and
cardiac tamponade ensues, cardiac
position alternates, with the heart
returning to its original position with
every other beat, and electrical alternans
may be seen.
Electrical alternans: ECG change in which
the morphology and amplitude of the P,
QRS, and ST-T wave in any single lead
alternates in every other beat
Electrical alternans, when present, is
pathognomonic for tamponade
It is much more common in chronic
pericardial effusions that evolve into a
tamponade, however, and it is rarely
seen in acute pericardial tamponade.
How to confirm cardiac tamponade
Radiography
In acute pericardial
tamponade generally is not
helpful (unless a traumatic
pneumopericardium is
present).
Because small volumes of
hemopericardium lead to
tamponade in the acute
setting, the heart typically
appears normal
This is in contrast to the
water-bottle appearance of
the heart with chronic
pericardial effusion. This
latter condition is tolerated
for a long period.

Emergency management
Fluid rescuscitation
Presence of a pneumothorax or hemothorax,
associated with penetrating cardiac trauma
tube thoracostomy.
Bedside echocardiography/sonography
Pericardiocentesis temporary relief
Refer when patients hemodynamic stabilized
Pericardiocentesis
Aspiration of 5 to 10 mL of blood may result in
dramatic clinical improvement.
<<< total intrapericardial volume to just below
critical level allows compensatory mechanisms
to maintain adequate hemodynamics.
Pericardiocentesis
Blood in the pericardial space tends to be
clotted, and aspiration may not be possible.
Possible complications
production of pericardial tamponade
laceration of a coronary artery or lung
induction of cardiac dysrhythmias

Technique: Approach
Parasternal
approach
Through the left
5th or 6th
intercostal space
near the sternum.
The cardiac notch
in the left lung and
the shallower
notch in the left
pleural sac leaves
part of the
pericardial sac
exposedthe bare
area of the
pericardium
Technique: Approach
Infrasternal
approach
Passing the needle
superoposteriorly
At this site, the
needle avoids the
lung and pleurae
and enters the
pericardial cavity
Care must be taken
not to puncture
the internal
thoracic artery or
its terminal
branches.
Technique: Equipment
Surgical preparation set: gauze, antiseptic
solution (povidone iodine 10%)
Local anestethics: lidocaine 2%
16 to 18G catheter with 6 (15 cm) or more
length needle
Syringe
Three-way stopcock
Electrocardiography
CVP monitor
Technique: Procedure
Monitor tanda vital, EKG, dan CVP pasien
sebelum, selama, dan setelah prosedur.
Preparasi sebelum prosedur pada area xiphoid
dan subxiphoid (jika waktu cukup)
Anestesi lokal di tempat pungsi (jika perlu)
Tusuk kulit 1-2 cm di inferior xiphochondrial
junction kiri dengan sudut 45o
Dorong jarum hati-hati ke arah sefalad menuju
ujung skapula kiri
Jika jarum didorong terlalu jauh (myokardium),
pola cedera muncul pada monitor EKG
Pola cedera misal: perubahan ekstrem gelombang ST-
T atau membesarnya kompleks QRS
Tarik jarum sampai pola EKG sebelumnya muncul
kembali
Ketika ujung jarum memasuki perikardium,
aspirasi cairan sebanyak mungkin
Pola cedera mungkin muncul lagi saat aspirasi karena
epikardium kembali mendekat dengan perikardium.
Tarik jarum sedikit. Jika pola menetap, tarik jarum
keluar.
Setelah aspirasi selesai, cabut tabung jarum,
sambungkan ke 3-way
Jarum plastik perikardiosentesis dapat dijahit
atau diplester dan ditutup kasa kecil.
Jika gejala tamponade persisten, dapat
dilakukan dekompresi berulang.
Setelah hemodinamik pasien stabil, rujuk
unutk penanganan definitif.
References
Marx JA (ed). 2006. Rosen's Emergency
Medicine: Concepts and Clinical Practice, 6th
ed. USA: Elsevier.
Moore KL, Dalley AF, Agur AM. 2010. Clinically
Oriented Anatomy, sixth edition. USA:
Lippincott Williams & Wilkins
American College of Surgeons Committee in
Trauma. Advanced Trauma Life Support for
Doctors, Student Course Manual, 8
th
edition.

Thank you