Cardiac Tamponade - The Original Kings of County

Cardiac Tamponade and Pericardiocentesis

Summary by Dr. Kaycie Corburn

Presented by Dr. Sally Bogoch

The Case: 60 yo M PMH metastatic lung cancer, HTN, DM, former smoker presents to the ED with acute onset shortness of breath. Vitals in triage revealed tachypnea and tachycardia. Initial work-up revealed low voltage on EKG, enlarged cardiac silhouette on chest x-ray, bedside ECHO with pericardial effusion without tamponade, and CTA with large left lobe mass and segmental pulmonary embolism. The patient was anticoagulated with heparin infusion. While boarding in CCT and awaiting a non emergent pericardial window, he became acutely dyspneic with elevated heart rate and subsequently asystolic. Pericardiocentesis was performed bedside with return of spontaneous circulation. The patient was brought to the OR for pericardial window and admitted to the ICU. A short while later the patient expired.

Cardiac Tamponade and Pericardiocentesis:

Definition:

-Cardiogenic shock causes by accumulation of fluid, pus, blood, clots, or gas in between the pericardium and myocardium as a result of effusion, trauma, or rupture of the heart.

Etiology of tamponade in non-trauma patients:

-Metastatic malignancy 40%

-Acute idiopathic pericarditis 15%

-Uremia 10%

-Bacterial or tubercular pericarditis 10%

-Chronic idiopathic pericarditis 10%

-Hemorrhage (anti coagulation) 5%

-Other 10%

Tamponade physiology:

-Increased pericardial pressureincreased RA pressuredecreased RA fillingdecreased preloaddecreased left sided fillingdecreased cardiac outputcardiovascular collapse

Clinical diagnosis:

-Beck’s triad: Muffled heart sounds, hypotension, JVD

-All three criteria are presents in a minority of cases

-A larger portion of patients with cardiac tamponade will have one of the three criteria

EKG:

–Electrical alternans

-present in a minority of cases

–Low voltage

-less than or equal to 5mm amplitude of QRS segment in all limb leads

-less than or equal to 10mm amplitude of QRS segment in all precordial leads

Echocardiogram:

-Presence of a pericardial effusion with right ventricle collapse in diastole

Risk factor for cardiac tamponade:

-Metastatic cancer,

-End stage renal disease,

-Recent surgery

-Chest radiation

-Trauma

-Other

ED management:

-All emergency room measures are only temporizing

-Volume expansion with intravenous fluid bolus

If hemodynamically unstable, in shock, or cardiovascular collapse…

Pericardiocentesis

Absolute Contraindications to pericardiocentesis:

-Stable vitals (schedule an elective pericardial window by cardiothoracic surgery)

-Traumatic cardiac tamponade (perform a thoracotomy)

Relative contraindications to pericardiocentesis:
-Mycocardial rupture

-Aortic dissection

-Severe bleeding disorder

The procedure:

-Prepare materials: code cart with resuscitation equipment, hemodynamic monitors, bedside ultrasound machine, EKG machine, 18 gauge spinal needle, 3 way stop cock, 20cc syringe, antibacterial skin cleanser, sterile gloves
-Palpate xyphoid process and landmarks

-Put on personal protective equipment

-Prep a sterile area over the patient’s chest and subxyphoid region with chloroprep or betadine scrub; if time allows place a sterile drape over the patient’s chest

-If time allows, use local anesthesia for patient comfort

-If patient is stable enough, raise head of bed 30-45 degrees

-Ideally have ultrasound available for this procedure; if ultrasound is not available, have the patient on EKG monitoring to know when the needle hits the myocardium; if neither are available, blind approach is a last resort (associated with high morbidity and mortality compared to a monitor setting)

-Hold ultrasound (curvilinear or cardiac probe) in the subxyphoid position to visualize the pericardial effusion

-Insert the 18 gauge spinal needle with the stylet in place at a 45 degree angle just next to the ultrasound and directly under the xyphoid process

-Once the needle is through the skin, remove the stylet from the spinal needle and attached the 3 way stop sock and 20cc syringe to the needle

-Advance the needle toward the patient’s left shoulder while aspirating continuously

-Stop advancing once you have a flash of blood/fluid

-Drain fluid until patient’s vital signs improve; even a small amount of fluid drainage can restore cardiac output

-More fluid can be removed by attaching tubing to the open port of the 3 way stop cock

-Remove enough fluid until vital signs normalize or no more fluid can be removed

*If a pericardiocentesis tray is not available, most necessary supplies can be found in other kits such as the paracentesis/thoracentesis tray or central venous catheter tray

*If you use a central venous catheter tray, this will allow for Seldinger technique to guide a flexible catheter over a wire into the pericardial space to provide continual drainage of pericardial fluid

Parasternal approach:

-Insert the spinal needle perpendicular to the chest wall in the 5th intercostal space, just lateral to the sternum

-Once you are through the skin, remove the stylet and attach the 3 way stop cock and 20cc syringe

-Use ultrasound guidance to guide the needle (while aspirating) into the pericardial fluid collection

EKG monitoring:

-If no ultrasound is available, a sterile alligator clip can be attached from the proximal end of the metal of the spinal needle to a precordial lead from an EKG machine

-If you see ST segment elevations, as you are advancing your needle, this indicates that you have advanced the needle too far (the needle is hitting the myocardium)

-If this happens, withdraw the needle until ST segment elevations resolve and re-direct the needle

After the pericardiocentesis

-Obtain a chest x-ray to check for immediate complications such as pleural effusion or pneumothorax

-Continue to monitor the patient for recurrent tamponade

-Arrange immediate definitive care though the cardiothoracic surgery service

Complications of pericardiocentesis:

-Cardiac dysrhythmia

-Myocardial puncture

-Pneumothorax

-Coronary vessel injury

-Peritoneal puncture

-Liver/stomach injury

-Diaphragm injury

-Injury to the internal thoracic artery

-Death

Take a look at this link for more information and an instructional video:

http://www.nejm.org/doi/full/10.1056/NEJMvcm0907841

References:

Fitch, MT. Emergency Pericardiocentesis. New England Journal of Medicine. (2012). 336:e17.

Guyatt, GH. Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians Practice Guidelines. Chest. 2012. 141(2) 53-70.

Ristic, A., et al. Triage Strategy for Urgent Management of Cardiac Tamponade. European Heart Journal. 2014; 35(34): 2279-2284. <accessed through Medscape>

Roberts, RJ. 2014. Clinical Procedures in Emergency Medicine 6th Ed. New York, NY: Saunders.

Schiavone, WA. Cardiac Tamponade: 12 pearls in diagnosis and management. Cleveland ClinicJournal of Medicine. (2013). 80:2, 109- 116. February 2013.

Spodick, DH. Acute Cardiac Tamponade. New England Journal of Medicine. 349:7. 685-690. August 14, 2003.

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.