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BY Cian McDermott​

The case:

A 35 female was brought to ED by ambulance following a sudden collapse at home. At the scene – skin cold, Blood Pressure un-recordable, semi-conscious.

In ED, she was:

  • Shocked, grey, diaphoretic but talking

  • BP 50/39 mmHg, HR 130/min

  • Femoral arterial line – pH 7.15, pCO2 42, lactate 11.8, BE -13.8

  • Peripheral adrenaline IV infusion 20mcg/min

Focused cardiac ultrasound shows:

  • Large pericardial effusion (anechoic fluid in pericardial sac)

  • US signs of tamponade:

           Large pericardial effusion

           RA, RV collapse

           IVC dilated

Video 1: Anechoic stripe between RV free wall & pericardium beside the liver, RA collapse

Video 2: Large anterior anechoic effusion >2cm

Video 3: RV Obstruction

Video 4 - IVC distended distal to the IVC - RA junction

Immediate management:

  • Immediate live US-guided pericardiocentesis (dual operators – 1 US, 1 needle insertion)

  • Parasternal approach – 3mls of fresh blood aspirated, catheter in situ on free drainage

  • Immediate increase in BP (75mmHg systolic)

  • CVL in RIJV

  • Transferred to OT

  • Subxiphoid pericardial evacuation of extensive clotted haemopericardium

  • ICU course uncomplicated – extubated, no pressors required

What the experts say:

  • Pericardial effusion is the presence of fluid in the pericardial sac that exceeds the physiological amount (50ml)

  • Cardiac tamponade is a clinical diagnosis, emergency pericardiocentesis guided by US is a life-saving procedure

  • Tamponade physiology occurs when pressure in the pericardium exceeds the pressure of the cardiac chambers, resulting in impaired cardiac filling, see diagram 1

Diagram 1:

Cardiac US findings suspicious for tamponade:

  • Right atrial systolic collapse – inversion of RA free wall for more than 1/3 of ventricular systole has a sensitivity of 94% and specificity of 100% for tamponade (see diagram 2)

  • Right ventricular diastolic collapse – sensitivity 60 – 90%, specificity 85 – 100% (see diagram 2)

  • Dilation of IVC – dilated IVC (>2.1cm) with less than 50% decrease in diameter at inspiration (sensitivity 97%, specificity 40%)

Diagram 2:

The procedure:

  • The procedure requires removal of pericardial fluid, it is a temporising measure that serves as a bridge to definitive care

  • In traumatic causes, the preferred option may be surgical drainage via a pericardial window or a pericardectomy

  • In general, consider pericardial drainage if the effusion is > 20mm seen on US and your patient is hypotensive

  • Success rate for this procedure when guided by US is 97% with overall complication rate of 4.7% (landmark based pericardiocentesis complication rate 20%)

  • Not a single standardised approach – can use subcostal, apical or parasternal approach to access the pericardial space

  • The subcostal approach is most commonly and easiest performed in most patients – use a long 16 or 18-gauge needle inserted between the xiphoid process and the left costal margin at an angle of 30 degrees, directed towards the left shoulder. Advance the needle tip, continuously aspirating

  • If a pigtail catheter is inserted for prolonged drainage, confirm the position of the needle/ wire in the pericardial space before dilation of the tract for a drain

  • Needle entry site should be determined by location of the largest visible amount of fluid seen on US

  • Live, real time US guided pericardiocentesis is often a 2-person approach, 1 holding the probe, the other to advance the needle. In clinical practice this is often done using static ultrasound assistance


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