037. Pericardiocentesis

Ultrasound is the key to make the diagnosis.

The only way to fix it is to drain the fluid.

Pericardial space has a negative pressure – suction force that helps open up the RV for filling.

Size of pericardial effusion doesn’t matter on symptoms. Its all about the timing of how quickly it was created or filled.

Tamponade: the state of shock. Hard time filling the ventricles. Not a systolic problem; it is a diastolic dysfunction (not filling the heart – like no gas in a car).

When pressure increases past RV pressure: no suction, no filling. Also septum pushes out causes decreased LV filling causing hypotension.

EKG findings: electrical alternans: all this means is the heart is flowing back and forth in the pericardial fluid. It does not tell you the person is having tamponade or not.

Low BP/JVD/muffled heart sounds (triad): only 33% of cases – primarily right before the patient codes on you.

Echo: Subxiphoid: RV diastolic collapse: looks like someone’s jumping on a trampoline. LA should never collapse. Look at IVC as well: looks for dilated IVC: no HR changes.

Treatment:

IV Fluids: Give fluids, but if they get worse, likely related to RV dilating causing decreased LV filling causing hypotension.

Levophed isn’t really going to help. Dobutamine (increased contractility, increased HR) won’t help.

Bipap: decreased preload – will hurt filling.

Ultrasound pericardiocentesis: Do apical or 4 view to get the smallest amount of tissue between needle and heart. Consider injecting 1cc of agitated saline in during to confirm needle is in pericardium rather than ventricle. Will likely need catheter, eventually needs surgery.

 

References

The Crashing Tamponade, Haney Mallemat, The Crashing Patient Conference 2015

037. Pericardiocentesis

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