10th Block

Circulation system

Cardiac Tamponade

P. Pujowaskito

© 2014 General Ahmad Yani University 1

 Anatomy & Physiology
• Maintains Heart’s position
• Barrier of infection
• Lubrication

50 cc of fluid,
2-4 mmHg

2 mm 2
Cardiac tamponade is a life-threatening condition caused by
fluid under pressure around the heart, characterized by
increased intrapericardiac pressure that leads to poor cardiac
diastolic filling and decreased cardiac output

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 Etiology

1. Hemopericardium (trauma or aortic dissection). Or

iatrogenic like anti-coagulation therapy, transvenous
pacemaker, diagnostic pericardiocentesis, CPR,
cardiac catheterization or other invasive cardiac
procedures.
2. Neoplasm.
3. Pericarditis from radiation therapy, infections, or drug
reactions such as hydralazine or procainamide.
4. Other Causes: Pericarditis, Acute Myocardial
Infarction, Tuberculosis, Radiation Damage, Bacterial,
Cardiomyopathy, Lupus, Or Dissecting Aortic
Aneurysm.
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Pathophysiology

 Impairment of ventricular
diastolic filling caused by
pressure of pericardial
sac
 And by bulging of
ventricular septum
into LV
 Stroke volume and
cardiac output fall

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Pathophysiology

 Point:
1. Decrease intracardiac
volumes and increased
ventricular diastolic
filling pressure
2. Increase of the
intrapericardial
pressure producing
external cardiac
compresion

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 Production of
Cardiac Tamponade
Pericardial sac
Right atrium
BP

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 Production of
Cardiac Tamponade

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Pressures in Patient With
Cardiac Tamponade

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 Cardiac Tamponade
 Clinical manifestations
• Central venous pressure elevated
• Early rapid ventricular filling inhibited
• Intracardiac pressures equalized during diastole
• Pulsus paradoxus usually present

 Clinical signs
• Pulsus paradoxus
• Pericardial friction rub may be present
• Heart size on x-ray may be normal
or enlarged
• Echocardiogram
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Cardiac Tamponade

 Beck’s triad:
1. Hypotension,
2. Jugular venous
distention, and
3. Muffled heart sounds

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Due to the swinging motion of the heart
within the pericardial sac 17
Pericardial Tamponade

 Chest x-ray
• Widened mediastinum
• Pneumo- or
hemothorax

• Note rounded bottle shape to

left side of heart

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Echocardiography
1. The imaging technique of
choice for diagnosis of
pericardial effusion and cardiac
tamponade
2. Diastolic right atrial and right
ventricular collapse are the
most commonly used clues for
tamponade
3. A distended IVC or IVC
plethora,
4. An exaggerated “paradoxical”
increase in right-sided inflow
velocities with an exaggerated
decrease in leftsided inflow
velocities
5. A paradoxical motion of the
septa
6. The swinging motion of the19
heart within the pericardial sac
Echocardiography

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 Treatment

1. Analgesics such as morphine

2. Diuretics such as furosemide, may stabilize the
condition until the fluid can be removed.
3. Bedrest with the head slightly elevated minimizes
the workload on the heart .
4. Oxygen reduces the workload on the heart by
decreasing tissue demands for blood flow.
5. The cause of the tamponade must be identified and
treated. Treatment of the cause may include
medications such as antibiotics, and surgical repair
of injury.
6. Pericardiocentesis may relieve symptoms and can
be life-saving.
7. Surgical pericardiectomy may be required if scarring
is a cause of tamponade.
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Treatment

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 Pericardiocentesis

 Indications
• Immediate threat to life
• Severe hemodynamic impairment
• Fall in systolic blood pressure >30 mm Hg

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 Pericardiocentesis

 General principles
• As of 2000 = echocardiography used to
guide pericardiocentesis
• Direct subxyphoid techniques only used in
dire medical emergency
• ECG and hemodynamic monitoring
• Full resuscitation equipment available

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 Pericardiocentesis

 Equipment
• 16-gauge short-bevel large-bore needle
• 30- or 50-mL syringe
• Echo- or ECG-guided (V lead)
• Local anesthetic
• Sterile supplies and povidone-iodine
solution

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 Pericardiocentesis

 Technique
• Patient in supine position, upper
torso elevated
• ECG limb leads attached to patient
• Use echocardiography guided procedure
(rarely: ECG-guided, V lead)
• Subxiphoid approach
• Continuous aspiration
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 Pericardiocentesis

Hub of needle
angeled
approximately 15 Apical
degrees above skin area

Paraxihopid
area

Most Common Sites of Blind and Image-Guided Insertion of the Needle for
Pericardiocentesis. In the paraxiphoid approach, the needle should be aimed
toward the left shoulder. In the apical approach, the needle is aimed internally. 28
 Pericardiocentesis

 For historical interest: ECG-guided

needle advancement

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 Pericardiocentesis

 Hazards
• Cardiac arrhythmias
• Laceration of myocardium or
coronary arteries
• Injection of air into cardiac chambers
• Hydrothorax or pneumothorax
• Hemorrhage from laceration may
produce tamponade
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Pericardiocentesis

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 Prognosis

Tamponade is life
threatening if untreated.
The outcome is often good
if the condition is treated
promptly, but tamponade
may recur.

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 13 th
Block
Circulation system

TQ, 4 your attention

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© 2009 General Ahmad Yani University
 13th Block
Circulation system

 Refference
1. Hoit BD. Management of Effusive and Constrictive Pericardial
Heart Disease. Circulation 2002;105;2939-2942
2. Hoit BD. Disease of the Pericardium. In: Hurst’s The Heart.
Tenth Edition. International Edition: McGraw-Hill 2008; p.
2068-2072
3. LeWinter MM. Pericardial Disease. In: Braunwald’s Heart
Disease, A Textbook of Cardiovascular Medicine. Eighth
Edition. Philadelphia: Saunders Elsevier 2008; p. 1829-1853
4. Restrepo CS,Lemos DF,Lemos JA, et al. Imaging Findings in
CardiacTamponade with Emphasis on CT. RadioGraphics
2007; 27:1595–1610
5. Spodick DH. Current concepts: Acute Cardiac Tamponade. N
Engl J Med 2003;349:684-90.
6. Valley VT, Fly CA. Pericarditis and Cardiac Tamponade. E-
medicine [serial online]; 2005. Available from URL:
http://www.emedicine.com/EMERG/topic412.htm
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© 2009 General Ahmad Yani University