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Cardiac tamponade
Muhammad Aprianto Ramadhan
Stase BedahFK UGM/RSST Klaten
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Anatomy
The pericardium, whichis the membranesurrounding the heart,is composed of 2 layers.
The thicker parietalpericardium is the outerfibrous layer; thethinner visceralpericardium is the innerserous layer.
The pericardial spacenormally contains 20-50mL of fluid.
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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 SHOCKLIFE 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 aprogressive increase in CVP to a level greater than 15 cm H2O.
An increasing CVP in a hypotensive patient indicates that the normalcompensatory responses are unable to maintain an adequate cardiac output.
A simultaneous decrease in the CVP and blood pressure, which can occurprecipitously and without warning, signals decompensation and imminentcardiac arrest.
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When to suspect cardiac tamponade?
History of penetrating trauma to the chest or upperabdomen 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
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How to confirm cardiac tamponade?
Ultrasonography98.1% sensitivity, 99.9% specificityfor pericardial effusion.
Tamponade: simultaneous presence of pericardial fluid
and diastolic collapse of the right ventricle or atrium
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How to confirm cardiac tamponade?
Electrocardiography Swinging heart phenomenon when
fluid accumulates to a critical extent andcardiac tamponade ensues, cardiacposition alternates, with the heart
returning to its original position withevery other beat, and electrical alternansmay be seen.
Electrical alternans: ECG change in whichthe morphology and amplitude of the P,QRS, and ST-T wave in any single leadalternates in every other beat
Electrical alternans, when present, ispathognomonicfor tamponade
It is much more common in chronicpericardial effusions that evolve into atamponade, however, and it is rarelyseen in acute pericardial tamponade.
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How to confirm cardiac tamponade
Radiography
In acute pericardialtamponade generally is nothelpful (unless a traumaticpneumopericardium ispresent).
Because small volumes ofhemopericardium lead totamponade in the acutesetting, the heart typicallyappears normal
This is in contrast to the
water-bottle appearance ofthe heart with chronicpericardial effusion. Thislatter condition is toleratedfor a long period.
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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
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Pericardiocentesis
Aspiration of 5 to 10 mL of blood may result in
dramatic clinical improvement.
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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
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Technique: Approach
Parasternalapproach Through the left
5th or 6th
intercostal spacenear the sternum.
The cardiac notchin the left lung andthe shallower
notch in the leftpleural sac leavespart of thepericardial sacexposedthe barearea of the
pericardium
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Technique: Approach
Infrasternalapproach Passing the needle
superoposteriorly
At this site, theneedle avoids thelung and pleuraeand enters thepericardial cavity
Care must be takennotto puncturethe internalthoracic artery orits terminalbranches.
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Technique: Equipment
Surgical preparation set: gauze, antisepticsolution (povidone iodine 10%)
Local anestethics: lidocaine 2%
16 to 18G catheter with 6 (15 cm) or morelength needle
Syringe
Three-way stopcock Electrocardiography
CVP monitor
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Technique: Procedure
Monitor tanda vital, EKG, dan CVP pasiensebelum, 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
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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 munculkembali
Ketika ujung jarum memasuki perikardium,aspirasi cairan sebanyak mungkin
Pola cedera mungkin muncul lagi saat aspirasi karenaepikardium kembali mendekat dengan perikardium.Tarik jarum sedikit. Jika pola menetap, tarik jarumkeluar.
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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.
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References
Marx JA (ed). 2006. Rosen's EmergencyMedicine: Concepts and Clinical Practice, 6thed. USA: Elsevier.
Moore KL, Dalley AF, Agur AM. 2010. ClinicallyOriented Anatomy, sixth edition. USA:Lippincott Williams & Wilkins
American College of Surgeons Committee inTrauma. Advanced Trauma Life Support forDoctors, Student Course Manual, 8thedition.
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Thank you