pericardial systosis ?

[Polar Bear 4/31]

Please bear with me. I Have NO medical training other than CLS, so I just spelled it phonetically. I am asking about the possibility of decompressing the membrane surrounding the heart after some sort of trauma in an U/W enviorment. Has anyone had to do this in real life?

[18C/GS 0602]

I am not sure, but are you talking about pericardial tamponade? Pericardial tamponade (PT) is when fluid accumulates between the heart muscle and the covering of the heart called the pericardial sac. If acute just a small amount of fluid in this space can greatly decrease the hearts ability to pump blood, and can rapidly kill someone. PT is seen in about 2% of penetration injuries to the chest. Clinically the textbooks tell you that you see a decreased B.P., distended neck veins and muffled heart sounds, but from my own limited experience and from what others have told me PT can present in less classic forms such as isolated shortness of breath. This is one of those emergencies like a tension pneumothorax where a patient of the verge of death and can be effectively treated. The treatment is a pericardiocentesis (stick a needle into the area between the heart muscle and pericardial sac and remove the fluid). In the hospital PT can be diagnosed using ultrasound, and then be used to guide your needle into the pericardial space. In the UW environment you would not have access to US and you would have to make the diagnosis solely on clinical grounds. Furthermore you would have to perform the pericardiocentesis blind with out the help of US.
I have not performed a pericardiocentesis but I have seen a few. It is not something I would want to do blind unless I was very certain PT was occurring, or if the patient was almost dead.

[Sacamuelas]

I think Bdonham is referring to the condition you describe.

If I go by what you typed though, then I think you referring to terminology describing the situation verses the actual medical diagnosis, Pericardial tamponade. "Pericardial stenosis" is my guess of what you were attempting to spell. Stenosis literally means an "abnormal narrowing of a bodily canal or passageway".

Therefore, you are most likely describing the process that Bdonham refers to in his post.

Note- there is one similar situation that "sort of " fits with your description. The space surrounding the heart (pericardium) can be compressed from the outside forces during a tension pneumothorax, and that condition can be treated by needle aspiration initially too. You wouldn't be "decompressing the membrane around the heart" but in laymen's terms it might be described in a similar way since both Tx use needle decompression to relieve the pressure(one from the pericardial sac and the other from the pleural sac around the lung).

[greg c]

bdonham has it nailed, I would guess pericardiocentesis is the word you are going for. I have done it ten times or so, usually at code arrest settings in the hospital. Not technically difficult, but anytime you blindly are sticking sharp pointy things into people, you'd better hope your anatomic landmarks are reliable. I would imagine that this could be a problem in a trauma setting.

Of note, deciding whether you truly have tamponade can be tricky, especially in the prehospital setting where U/S and other diagnostic modalities are not available...

For example: you stick a needle into someone who is actively dying on you. (I do this from an entry point at the xiphoid process, aiming toward the middle third of the (Left) clavicle, at a very shallow angle to the skin, actively aspirating as I go. I'll add that in practice some guys do it differently) Let's say as you advance the needle you begin to get a brisk bloody return- how do you know if you've got a bloody pericardial effusion versus a needle that's just entered a heart chamber? Sure there's all these textbook ideas of hooking up an EKG lead to the needle and watching the EKG spike when you hit myocardium but I guarantee you this will not be possible in the chaotic theater of an arrest situation. You might say that the patient should get better- in fact, s/he should get WAY better if an acute tamponade is the case. I guess if you're lucky enough that tamponade is your ONLY problem that may happen. However, in the real world things usually aren't so clean, eh?

I will add that a check for pulsus paradoxus may be helpful in your clinical exam, and requires only a blood pressure cuff and a stethoscope. I would also add that almost no one does it correctly, and that in a loud environment it is likely worthless. And that it is not a very sensitive nor specific test. I won't waste time typing a description you can likely find on the internet, but if you read about it and still have questions I'll be happy to give my input.

Hope this helps.

-G

[Polar Bear 4/31]

Thanks for your patience. Bdonham described exactly what I am talking about. Now that I know the proper term and spelling, I'll do some more research on my own.

[18C/GS 0602]

Greg C- Welcome.

[NousDefionsDoc]

Polar Bear, square away that sig line.

[greg c]

BDonham, thank you. I look forward to having some thoughtful discussion with you all.

[Polar Bear 4/31]

Roger Sergeant.

[Doc T]

Originally posted by greg c
bdonham has it nailed, I would guess pericardiocentesis is the word you are going for. I have done it ten times or so, usually at code arrest settings in the hospital. Not technically difficult, but anytime you blindly are sticking sharp pointy things into people, you'd better hope your anatomic landmarks are reliable. I would imagine that this could be a problem in a trauma setting.


-G

what were your indications for doing a pericardiocentesis since I am assuming they were medical codes? Any survivors?

I have taken residents through pericardiocentesis on a few occasions.... no survivors. The patient is usually s/p a motor vehicle condition in full arrest and on arrival we do bilateral chest tubes and pericardiocentesis to basically treat reversible causes of the arrest if they are present (tamponade or tension pneumothoraces...this may partially answer one of NDD's other questions...)

The other grop that may benefit are those with penetrating injuries in whom you suspect tamponade and in my hands they would undergo a thoracotomy instead either emergently or urgently depending on the scenerio and hemodynamic status of the patient.

I have, in my experience, two neurologically intact survivors of ER thoracotomy from pericardial tamponade from stab wounds.....both could have had a pericardiocentesis initially to try and revive them if the capabilities for an ER thoracotomy weren't available.

Contrary to popular belief however, pericardial blood does clot and this cannot be evacuated through a catheter.

doc t.

[greg c]

"what were your indications for doing a pericardiocentesis since I am assuming they were medical codes?"

Best explanation of why a medicine guy is running around with a needle follows...

Two schools of thought on running codes:

First school: do every possible intervention in attempt to treat all possible etiologies of a code.

Second school: do everything to treat etiology of code as it reasonable applies to patient's hospitalization history.

My experiences have been part of both schools of thought. Given cardiac tamponade being on the short list of PEA etiologies, I have stuck patients in vain hopes of resurrecting the dead. No success.

However the second school of thought has led me to pericardiocentese patients as well. Common medical service etiologies (in my experience, anyways) of chronic pericardial effusions are patients with renal failure, cardiac failure, severe hypothyroidism, malignant pericardial effusions. Most of these patients are hypotensive for any number of reasons, and do not demonstrate the hallmark right atrial end diastolic collapse on ECHO, and thus clinically do not have tamponade. BUT if they code, all bets are off, and the needles come out. These guys usually have nonbloody effusions (except the malignant effusions) and thus can be drained fairly well. That's not to say that medicine patients can't develop an acute effusion as well- how about a free wall rupture post MI?

The above in addition to the fact that the on call medicine team runs all the codes in our 500 bed level one trauma center and end up coding high effusion risk folks like post cardiac surgery patients, hospitalized trauma patients, etc, explains why I at least have to entertain the idea of cardiac effusion with tamponade more often than I would like to.

As to the second question, no one that I have coded has ever survived directly as a result of percardiocentesis- not that I could tell. That's the (crappy or challenging, depending on how you look at it) thing about Medicine patients, there's never just one thing wrong- it's hard to say sometimes which intervention worked. I can say that a Medicine patient with an effusion who codes has an almost nil chance at walking out of the hospital alive given the comorbidities a chronic effusion implies.

Now I've got a Q for you- does your hospital allow the ER docs to do thoracotomies emergently?

[Doc T]

at the hospital where I am currently a trauma attending we have an ER residency as well as a surgical residency. I have taken residents from both specialties through ER thoractomies. The ER attendings have not, to my knowledge, ever performed an ER thoracotomy at my present institution. I am not certain if any have actual "privileges" to do so as its never become an issue.... trauma attendings take in house call as well as senior surgical residents and at least one of us responds to every high acuity trauma.

The hospital of my training had a separate trauma area where no ER attending ever ventured except to ask for a consult.

edited to add that I don't really see a reason for anyone but a surgeon to perform an ED thoracotomy as no one else can finish what is only begun with opening the chest. The times the ED residents have performed them the surgical residents have been scrubbed in the OR and were unavailable.

doc t

[greg c]

Thanks, had that discussion in a different venue, seems that your thoughts were the general consensus as well, but it's always informative to see how other folks are doing things.

-G