55 Chinese woman, no PMH, no meds. P/w epigastric discomfort x 2 weeks, not responding to Pepcid Maalox. Presented to Elmhurst ED for worsening epigastric discomfort and generalized weakness. No fever/chill. + Mild dry cough. No chest pain. + Mild SOB with exertion. No abd pain, n/v/d/c/dysuria. No night sweats or weight loss, denied exposure to TB. No orthopnea, no leg edema. No recent travel, migrated to US 17 years ago.
EKG and CXR as below. Labs are within normal limit. Cardiac enzyme negative.
Bedside ultrasound found to have large pericardial effusion with RV collapse.
Patient was taken to CT surgery for pericardiocentesis. 1 liter bloody output drained.
Pericardial space usually has 15-50ml of fluid. The increase of such fluid can result from trauma (including CT surgery catheter perforation), infection, cancer, CHF, renal/liver failure, uremia, thyroid disease, and post-MI. In cardiac tamponade, patient can progress quickly to hypotension, bradycardia, and cardiac arrest.
On bedside ultrasound, once RV collapse is seen, diagnosis of pericardial tamponade is made, which mandates emergency pericardiocentesis.
- 18-gauge needle (or spinal needle to avoid dermal tissue clogging)
- 3-way stopcock with flexible tubing (for repeat drainage)
- 20-ml syringe
Choose between subxiphoid, parasternal, or apical access. Parasternal access has become more popular because of its close proximity to the heart (only have to go through chest wall, far from liver) and more direct visualization (the needle is in the same plane as the sono beam). Once the tip of the needle is in the appropriate space, agitated saline test can be used to confirm the position.
- Parasternal – insert the needle perpendicular to the chest wall in the fifth intercostals space, just lateral to the sternum.
- Subxiphoid – insert needle just below the xiphoid process and left costal margin. Enter the skin at 30-45 degree angle, aiming towards the left shoulder.
- Apical – insert the needle in the intercostals space below and 1cm lateral to the apical beat, aiming towards the right shoulder.
If an ultrasound machine is not available, use a wire with alligator clips at each end; attach one clip to the needle and the other to the EKG machine. ST elevation means direct contact of needle to myocardium; withdraw needle until ST segments normalize.
- Traumatic pericardial effusion and unstable VS, because they present as an indication for emergency thoracotomy.
- Myocardial rupture
- Aortic dissection
- Severe bleeding disorder
Ventricular rupture, arrhythmias, pneumothorax, myocardial and/or coronary artery laceration, and infection.
– Our patient: cell analysis of the effusion revealed malignant cells with unknown origin. 🙁
http://www.sonoguide.com/pericardiocentesis.html (Sonoguide for Emergency Physicians by Dr. Beatrice Hoffman)
http://www.nejm.org/doi/full/10.1056/NEJMvcm0907841 (video of pericariacentesis –subxiphoid approach- on NEJM)