On today's show we discuss the life-saving procedure of pericardiocentesis for pericardial tamponade.
Pericardial Tamponade
Is it Tamponade?
EMCrit Wee – Is it Tamponade with Jailyn Avila
Full, Fast and Strong (or Full, Fast, and Squeezed) [10.1016/j.bjae.2020.03.006]
No Bradycardia
Fluids
Vasopressors
Intubation
Great Review, including the idea of awake intubation with local anesthetic; from Ho et al. [Resuscitation 2009;80:272]
Where Should a Tamponade be Drained?
I used to think they were doing magic and fluoro in the cath lab, but at least in my experience, they are doing exactly what you are going to do
Ingredients
Indications/Contra-indications
Indications: tamponade that can't wait for drainage, semi-elective for effusion requiring drainage
Contra-Indications: essentially none in tamponade
Anatomical Knowledge
Expected vascular locations
Microskills
- Needle visualization on ultrasound
- Seldinger
Consent
Written consent is usually skipped in the emergent case
Bleeding, infection, puncture of heart, lung, liver, colon, stomach and/or coronary vasculature, death
Equipment List
Ideally
- Micropuncture Set with echogenic needle
- Ultrasound Probe Cover
- Central Line Bundle
- Pericardiocentesis tray
- 3-way stopcock
- 60 ml Syringe
- Local anesthetic with syringe and 22g 1.5 inch needle
In an emergency when you can't get the above
- Central Line Kit
- Sterile Gloves
Micropuncture Sets
Find out what the cath lab is using
You want a 21g 7cm (at least) needle with an echogenic tip
4F catheter
Pericardiocentesis Tray
I prefer the Cook Lock Tray [G04507]
It has an 8.3 F pigtail and comes with a multi-purpose adapter that allows you to use standard chest tube drainage set-up
Recipe
Cognitive Task Analysis of each step
Non-Sterile Set-Up
- Midazolam to Dazzle ‘Em
- Ultrasound Set-up to see site and puncture site without turning your head
Once Sterile
Mix up agitated saline if you have the time
Most cardiologists add 1 ml of air, some add 0.5 of air. I generally just rely on whatever air is contained in the 3-way stopcock
Some folks will even mix in 1ml of the pt's blood to make better bubbles
Ideally Longitudinal (i.e. In-Plane Approach)
Three Possible Locations
Para-Sternal
3rd or 4th ICS lateral to the sternum just above the rib
Must identify the internal mammary (internal thoracic) artery–throw on color doppler
Can go medial or lateral to the artery, but almost always, you will be going lateral
Above the Rib
Apical
5th or 6th ICS
Make sure there is no lung that will impinge on puncture site
Sub-Xiphoid
Sitting up if possible
Place an NGT
To the patient's left of the xiphoid
Aim for left shoulder
ECG Guidance
Place all the limb leads of a 12 lead machine and then hook V1 up via sterile alligator clip with wire to the needle
Pressure Transduction
Some folks, especially interventional cards, talk about using pressure monitoring
if you were to do this:
- set-up pressure monitoring
- set it to CVP
- attach to 3-way stopcock open to the needle, the syringe, and the pressure monitoring
- use the waveforms to determine where you are
problem in my mind has always been that RA and pericardium look very much the same. I can totally see it helping to differentiate a LV stick, but not much beyond that.
Aftercare
Chest radiograph
Decompensation after Pericardiocentesis
Consider perforation, re-accumulation, or pericardial decompression syndrome (PDS).
Pericardial Decompression Syndrome
Decompensation after rapid drainage; usually in chronic effusions
May complicate 5-10% of procedures
Tacit Knowledge (Tips and Tricks)
How to Perform Rapid vs. Slow
Complications & Trouble Shooting
Examples and Videos
This video from InterAnest is excellent:
Phil Rola from the ThinkingCC Site
Cardio Guide
Jailyn Avila on Pericardiocentesis
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Excellent topic Scott. Nicely done. Quite timely as we just had a thoracic dissection present in profound shock from hemorrhagic tamponade last week. We ended up doing a parasternal long axis approach, placed a drain, and the patient made it to the OR and survived surgery! A few thoughts: 1. I think a good compromise often times is to use the curvilinear probe. Seems to be nice happy medium between cardiac imagery and needle visualization. Especially for parasternal approach in patients with thicker chest walls. 2. Not a big deal at all but I never go through the rigamarole of… Read more »
For #2, yes you can visualize just with a hard push but not as well as with the classic technique. I use the former for midline confirmation, but sometimes you can’t see it as well as the old school.
3. I’ll have to give this a try sometime!
Those pearls were extremely helpful. Thank you for laying them out! I will look into the micropuncture sets. Another reason to use the linear or curvilinear probe for drainage (at low-depth): These probes’ piezoelectric crystals emit sound waves in a fixed direction toward the needle (and the waves return back to the probe similarly), thereby producing optimal needle visualization. In contrast, the sound waves from the phased array probe emanate in a fan-like formation from a narrow beam point. A differential timed excitation of the crystals leads to electronic steering/sweeping of the beam through tissue. Therefore, fewer sound waves encounter… Read more »
The Phil Rola video link doesn’t really have a video, but this one is good: https://www.youtube.com/watch?v=f5cZCP8oaLE
thanks!!! will add it