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

031. Surgical Airway Management

Cricothyrotomy

Indications:can’t intubate.

C/I: less invasive means, < 8 yo.

Equipment: Yanker suction, bougie preloaded in ET tube (6.0 tube), hemostat/needle driver, any scalpel (11 blade).

Anatomy: Space between thyroid cartilage and cricoid cartilage. Feeling for Adam’s apple and go below it (60% accurate).

Ultrasound: thyroid and cricoid cartilage actually are full of fluid so they appear black on ultrasound. White line is trachea lining.

US

Use non-dominant hand and hold the area. First incision is up/down (universal sign for death is across). Small incision until you get to the trachea. Then while scalpel is still in place, use hemostat to keep area open, then slide bougie thru the hole.

ET tube: cut it just above the balloon and then re-cap.

Complications: losing the hole, aspiration, blood in eyes, arterial hemorrhage.

References

Critical Procedures: Canthotomy and Cricothyrotomy, Mak Moayedi, The Crashing Patient Conference 2015.

031. Surgical Airway Management

029. Pediatric Airway Management

Neonatal Intubation

Suprasternal palpation: Suprasternal notch is at T2, basically where the tip of endotracheal tube should be after insertion. After thru the cords, palpate the notch with the other hand and feel for the tip of the tube. Once palpated, this should be the correct position (Paediatric Anaesthesia, 2013).

Clinical Cases

References/Resources

Resus.Me, Cliff Reid, Palpating neonatal tracheal tube

029. Pediatric Airway Management