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