Pericardiocentesis During Cardiopulmonary Resuscitation
by Doctor Traci Wolbrink.
Introduction.
Pericardiocentesis is performed in patients
with cardiac tamponade in order to restore cardiac output.
In this video, we will be demonstrating
the blind technique that is used when a patient has
an emergent need for pericardiocentesis such as when
a patient is receiving active cardiopulmonary resuscitation.
It should be noted, however, that whenever possible,
this procedure should be performed
by a specially trained health care professional
under ultrasound or fluoroscopic guidance.
Indications and contraindications.
Patients with cardiac tamponade have accumulation
of either fluid, blood, and or air
in the pericardial sac causing increased pressure,
limiting the ability of the heart to fill, thus,
decreasing cardiac output.
Signs of cardiac tamponade may include
tachycardia, narrow pulse pressure, hypotension,
pulsus paradoxis, jugular venous distension, decreased heart
sounds, enlarged cardiac silhouette on chest x-ray,
pericardial effusion on echocardiogram,
and low voltage QRS or electrical alternans on EKG.
Patients may present clinically with dyspnea, tachypnea,
tachycardia, poor perfusion, and, or change
in mental status, including agitation.
And, thus, a high degree of clinical suspicion
is required to make the diagnosis.
Patients at risk for pericardial tamponade
include those that have had recent cardiac surgery, trauma
or injury, cancer, renal disease, infection,
or autoimmune or inflammatory disorders.
Cardiac tamponade is one of the H's and T's that health care
providers should remember when providing
cardiopulmonary resuscitation on a patient who has pulseless
electrical activity.
There are no absolute contraindications to emergency
pericardiocentesis.
The following equipment is needed
for emergent pericardiocentesis.
Appropriate personal protective equipment,
including sterile gloves, emergency resuscitation,
medications, and equipment.
Cardiac monitoring devices.
Antiseptic skin cleanser such as chlorhexidine.
A large needle or spinal needle with the trocar removed.
A 20 or 21-gauge needle would be acceptable for a child.
And an 18 or 19-gauge needle would be acceptable
for an adult. Syringes--
It is helpful to have both a small 5 to 10-milliliter
syringe and a large 20, 30, or 60-milliliter syringe.
Slip-tip syringes are preferred, but Luer-Lok syringes
would also be acceptable.
A three-way stopcock with T-connector.
If the effusion is of large volume,
then the T-connector can be attached
to the spinal needle and the three-way stopcock
to the T-connector.
When the syringe is full, the stopcock
can be turned off to the patient to allow emptying
of the syringe into a container without having to disconnect
the syringe repeatedly.
Alternatively the syringe can be disconnected
from the T-connector, emptied, and then reattached.
Both of these techniques reduce the risk
of accidentally dislodging the needle
from the pericardial space while manipulating the syringe.
And both are most easily accomplished
with a second provider manipulating the syringe,
while the first provider stabilizes the needle.
Positioning and landmarks.
During active cardiopulmonary resuscitation,
the patient will be in supine position.
The xiphoid process should be palpated
in a subxiphoid approach which is between the xiphoid process
and the left inferior costal margin
will be the most optimal approach
to use when a patient is actively receiving CPR.
Procedure.
Start by cleansing the skin.
During active cardiopulmonary resuscitation,
the patient will not require a local anesthesia.
But this should be considered for elective or semi-urgent
procedures.
Connect the syringe to the needle
gently so that it may be easily removed without disrupting
needle position.
Cardiopulmonary resuscitation should be briefly paused
during the advancement of needle and aspiration of syringe.
Insert the spinal needle in the subxiphoid region
between the xiphoid process and the left inferior costal
margin.
Angle the needle underneath the ribcage,
no more than 45 degrees to the patient's skin,
and aim the needle towards the patient's left shoulder
as you continuously aspirate the syringe.
Short quick jabs as opposed to slowly advancing the needle
are required in order to penetrate
the parietal pericardium and to not tent it
against the visceral pericardium.
Advance and aspirate the needle until fluid, blood, and, or air
is obtained.
The distance from the skin to the pericardium
is based on body habitus.
If no fluid is obtained, withdraw the needle
to just underneath the skin and angle the needle more
posteriorly closer to a 45-degree angle
and re-advance the needle while continuously aspirating.
Remove and flush the needle after several failed passes.
If ultrasound is available, confirm the needles
in the pericardial space and not in the heart
with an apical four-chamber view.
Secure the needle at the skin with your other hand
to make sure the needle does not move unnecessarily
during the procedure.
Change to a larger syringe and continue removing fluid.
Remove the needle when you can no longer aspirate fluid
and remember to resume cardiopulmonary resuscitation.
Complications.
Complications include cardiac arrhythmias, pneumothorax,
accidental puncture of the heart or coronary vessels,
or injury to the stomach, liver, diaphragm,
or other internal structures or organs.
Post-procedure monitoring and documentation.
Continue cardiopulmonary resuscitation and monitor
for any change in hemodynamics.
An echocardiogram should be obtained as soon
as possible following the procedure
if return of spontaneous circulation is achieved.
Remember to document the amount and quality
of pericardial fluid removed and to send fluid samples
for analysis including cell count, protein, and culture
as indicated.
This concludes the video on pericardiocentesis
during cardiopulmonary resuscitation.
Please help us improve the content by providing us
with some feedback.