You have a patient in resus who is hypotensive. You make the wise decision to put the echo probe on the patient and you see this…
Uh oh! A pericardial effusion! Next question, is this tamponade?
You decide to look a little closer and notice this…
TAMPONADE!!
Check out some echo examples of tamponade
Ultrasound findings of tamponade: (from WikEM)
- Pericardial effusion (even small effusions can potentially cause tamponade)
- Diastolic collapse of the RA in atrial diastole
- Diastolic collapse of RV
- Plethoric IVC
Classic physical exam findings you may notice on your patient include Beck’s Triad:
1. Muffled heart sounds
2. Jugular venous distension
3. Hypotension
And remember.. tamponade physiology depends on the rate of fluid accumulation and the compliance of the pericardium, NOT the volume of the effusion. A slowly developing effusion may become quite large without causing tamponade, whereas a quickly filling effusion may cause tamponade with only a small volume.
**Always consider tamponade in a patient with PEA or penetrating trauma to the chest**
OK you diagnosed it, now what? The ultimate disposition for this patient will likely be to go to the OR with cardiothoracic surgery - so get them involved early. But if this patient is unstable (hypotensive, peri-code or already in arrest) you need to intervene now.
PERICARDIOCENTESIS
Subxiphoid approach (the most commonly used in the ED) - borrowed from LITFL
- Use a long 18-22 G spinal needle attached to syringe
- insertion: between xiphisternum and left costal margin
- direct towards the left shoulder at 40 degree angle to skin
- continual aspiration as needle approaches RV
- once pericardial fluid aspirated, can insert cannula (triple lumen central line or pigtail catheter) into pericardial space (using the same Seldinger technique we are familiar with)
- attach a 3 way tap and remove fluid with improvement in haemodynamics
Dr. Cameron Kyle-Sidell has a great video showing the parasternal approach, featured on Dr. Anna Pickens’ site EMin5.com
For even more info:
https://litfl.com/pericardiocentesis/
https://www.wikem.org/wiki/Pericardiocentesis
https://emin5.com/2016/07/11/pericardiocentesis/
For another ultrasound guided approach, check out ALiEM - https://www.aliem.com/2013/08/ultrasound-guided-pericardiocentesis/