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.