tamponade kordis

8/12/2019 Tamponade Kordis

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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

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