So a few nights ago I got pulled out of slumber to rush to the ER for an elderly patient who had arrested in hospital shortly after having been brought in for chest pain. The sharp ER doc had diagnosed a tamponade on a presumed aortic dissection, managed to get a needle in, aspirated some fluid and managed to get ROSC.
So when I got there we had a patient post-ROSC in rapid atrial fibrillation with a thready but palpable pulse. POCUS showed a large pericardial effusion with minimal LV filling. So here is what we did:
With the catheter in, we were able to drain. Note a couple of POCUS teaching points, always make sure to (1) visualize your guidewire in the right space, and (2) second, when using a dilator, you can note the disappearance of the proximal part of the guidewire as it is covered by the dilator. This tells you you have adequately dilated into the target structure – pericardium in this case, because it is possible (personal experience) to advance a dilator fairly deep, but not go through a perhaps fibrotic pericardium, and then result in pigtail mis-placement just outside of the target.
In part 2 you can also see the aspiration of the effusion and improved LV filling. The patient’s BP instantly rose to 140’s systolic.
More case details and POCUS teaching points to come in part 2.
ps – a sterile probe cover was unavailable immediately in the ER. By the time it showed up the pigtail was in. We didn’t feel we could wait. We doused it in alcohol.
Don’t you have infections there?
Sure you were wearing no face masks. For coherency sake.
But the imaging is superb! (please don’t ever use that probe on me, ok?)
Hi Nina, thanks for reading. As I stated in the post, we were unable to find a sterile sleeve in time. It seemed hemodynamics had to take precedence over sterility. Not to worry, if you do come by in tamponade, we’ll go blind!
Had a recent case of presumed ventricular free wall rupture post MI. Gentleman was a STEMI, awaiting interventionalist to come in, when he went from talking to cardiac arrest with narrow complex PEA. Got U/S on him quickly and showed massive pericardial effusion. Didn’t respond to usual ACLS which was ongoing in the background. Stuck a needle in him, took out 60cc blood, no change, effusion looked as big as previously. Interventionalist showed up and said it was futile. I continued for a while longer, but ETCO2 of 10, and flat A-line waveform, eventually ended up calling it.
Question I’d have is in the setting of an arrest in this situation, how much blood should we take out to see if we will get a response? In theory if this is a big enough rupture, we could drain out the entire circulating blood volume without getting cardiac output back.
I didn’t yet have time to post the part 2, which essentially illustrates the problem. Sadly a dissected aorta into the pericardium and an LV free wall rupture are both essentially unsurvivable. I will explain in part two how we got circulation back, only to re-establish a pressure gradient between aorta and pericardium, and tamponade to recur. It is a vicious cycle.
Thanks for reading.
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Hey mais vous êtes québécois, c’est génial !
What about francophone FOAMed de temps en temps ?
Bises de la France
En effet oui! En fait je n’y ai jamais trop pense, comme a peu pres tous les MD lisent l’anglais… Y aurait il de l’interet?
merci de lire!
Merci d’avoir publié cette vidéo. Pouvez-vous me donner une liste de l’equipement utilisé? C’est quel type de drain? Un pigtail normal?
De rien! Un pigtail 8.5F, je prefere les simple seldinger sans trocar – moins dangereux a mon avis. Jadis je mettais des voies centrales, surtout pleural. Pigtails mieux evidemment.