Circulation system
Cardiac Tamponade
P. Pujowaskito
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
3
Etiology
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
10
Pathophysiology
Point:
1. Decrease intracardiac
volumes and increased
ventricular diastolic
filling pressure
2. Increase of the
intrapericardial
pressure producing
external cardiac
compresion
11
Production of
Cardiac Tamponade
Pericardial sac
Right atrium
BP
12
Production of
Cardiac Tamponade
13
Pressures in Patient With
Cardiac Tamponade
14
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
15
Cardiac Tamponade
Beck’s triad:
1. Hypotension,
2. Jugular venous
distention, and
3. Muffled heart sounds
16
Due to the swinging motion of the heart
within the pericardial sac 17
Pericardial Tamponade
Chest x-ray
• Widened mediastinum
• Pneumo- or
hemothorax
18
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
20
Treatment
23
Pericardiocentesis
Indications
• Immediate threat to life
• Severe hemodynamic impairment
• Fall in systolic blood pressure >30 mm Hg
24
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
25
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
26
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
27
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
29
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
30
Pericardiocentesis
31
Prognosis
Tamponade is life
threatening if untreated.
The outcome is often good
if the condition is treated
promptly, but tamponade
may recur.
32
13 th
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