SIM Conference Pearls: Pericardiocentesis

Author: Maha Salama (and shout to Buzz Abrams for his expertise)

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Introduction:

• Pericardial tamponade is defined in Tintanelli’s as the accumulation of fluid that exceeds the stretch capacity of the pericardium –> precipitating hemodynamic compromise
• Pericardiocentesis = life saving procedure and skill needed by emergency physicians
  • frequently performed under ultrasound guidance when available
• In rapidly deteriorating patients in settings without immediate access to bedside sono, blind pericardiocentesis – just you, anatomic landmarks, a needle and a crashing human being – may be your only resuscitation option and you must act decisively

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Etiologies:

• Most common causes:
  • Iatrogenic
  • Malignancy
• Other important causes (in no particular order):
  • ESRD
  • Blunt and penetrating thoracic trauma
  • Pericarditis
  • Post MI (Dressler’s: rupture of the ventricular wall)
  • Autoimmune
  • Radiation
  • Infection
  • Hypothyroidism
  • TB (probably most common cause worldwide); viral and bacterial infections
  • Drugs (e.g., anticoagulants)
  • Aortic dissection

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Clinical Presentation:

• Classically:
  • Beck’s triad (distant heart sounds, hypotension, distended neck veins)
  • Pulsus paradoxus
  • As a practical matter, assessing for distant heart sounds and a pulsus in a busy, noisy ED is problematic
• Dyspnea, chest pain, inability to lie flat
• Chest fullness, nausea, esophageal pain, or abdominal pain from hepatic or visceral congestion
• Rare:
  • lethargy/weakness,
  • anorexia,
  • fatigue

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Physical Exam Findings and Their Clinical Reliability:

Clinical Finding	Sensitivity
Pulsus paradoxus	82%
Tachycardia	77%
JVD	76%
Diminished Heart Sounds	28%
Hypotension	26%

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ECG Findings:

• Classic:
  • Electrical alternans demonstrating the heart swinging towards and away from the ECG leads with each contraction
  • Low voltage
• Other findings:
  • Nonspecific ST-T wave changes,
  • Bradycardia in late stages
• Pericardial Tamponade is in the differential in PEA

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Echocardiography:

• During diastole, RV presses inward
• During systole, RA presses inward
• Right sided collapse portends rapid development of cardiac tamponade.
• Right atrial collapse during at least 30% of the cardiac cycle is more sensitive than the finding of right ventricular collapse for cardiac tamponade.
• In 25% of patients, a late finding is left atrium collapse.

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Management:

• The presence of an effusion is NOT necessarily an indication to perform ED pericardiocentesis in a stable patient.
• Clinical condition is determined by how fast the effusion accumulated:
  • Large, slowly developing effusions may exceed a liter can be well tolerated
  • Small, rapidly accumulating collections can be lethal
• IVF is a temporizing measuure (to maximize RV distension)
  
  
• For US guided pericardiocentesis, operator may elect a subxiphoid, parasternal, or apical approach (based on where the largest collection resides)
• Blind pericardiocentesis is performed using the subxiphoid approach exclusively.
  • Your needle (a spinal needle, central line needle, or the largest needle you can find, preferably with syringe attached) should be angled at 30 degrees, introduced to the left of the xiphoid in Larrey’s triangle, and directed toward the medial third of the left clavicle.
• In an emergent situation, there’s no time for local anesthesia.
• Apply negative pressure until you get blood return.
• Once blood is seen in the syringe, remove as much fluid as you can.
• You should see an immediate improvement in patient hemodynamics.
• Don’t worry about getting fancy with your stopcock and catheter.
• If you’re considering placing a catheter, this is likely not emergent and would be better served in a more controlled environment.
• As you may not know the etiologic diagnosis at the time of your intervention, and since blind pericardiocentesis is undertaken as a lifesaving maneuver, hard contraindications do not really exist when you are alone.
  
  
• HOWEVER: effusions and tamponade SHOULD NOT BE IMMEDIATELY DECOMPRESSED by needle in the setting of trauma:
  • In this setting, a definitive thoracotomy/surgical intervention is most appropriate

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Helpful Links/Resources:

• https://www.youtube.com/watch?v=XqZKK3J4cwo&t=776s
• https://everydayultrasound.com/
• Tintinalli, JE, Stapczynski JS, John M O, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8 th Edition. USA; McGraw-Hill; 2016.
• Roberts, J. R., Custalow, C. B., Thomsen, T. W., & Hedges, J. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th Edition. USA; Elsevier/Saunders; 2014.