This week’s case is a phenomenal save, brought about by an EM doctor, the Emory ED nursing team and on-call cardiology consultant. A forty-eight-year-old male patient and father of two young children presented in atrial fibrillation with a rapid ventricular rate. His tachyarrhythmia developed while running in the rain. History was that patient sustained a syncopal event, fall, and anterior chest wall trauma while running. Due to his history of recent atrial flutter and ablation 2 weeks prior, he had been placed on Xeralto. He presented with a BP of 70/40, HR in the 150s, ashen and dying. His moribund appearance was complicated by the fact that his core temperature was 30 degrees.
Despite rewarming, his unstable rhythm failed electrical cardioversion x2 and he required intubation and pressors. Bedside Rapid Ultrasound for Shock and Hypotension (RUSH exam) showed moderate-large pericardial effusion with suspected clot and tamponade physiology, possibly from type A dissection. Cardiology consultant arrived from the cardiac ICU to assist, attempting a technically difficult Trans-esophageal Echo. The ED team worked with speed and purpose. CT scanner was cleared for the patient and the team quickly obtained a CT angiogram chest and abdomen which showed no dissection but did note hemopericardium. The difficult decision was made that this patient would require drainage of his hemopericardium even though he was on a non-reversible anticoagulant if he was going to have a chance for survival! Pharmacy quickly got KCentra. Pericardiocentesis using a sub-xiphoid approach was attempted and unsuccessful due to a very limited sonographic window. The window was switched to an echo-guided apical approach, which was successful. The pericardiocentesis got 400ml blood out and relieved tamponade, and a pigtail drain was placed in pericardial space. His pressure immediately improved. Attached below are the pre- and post-CT scans of the patient, as well as a video clip of large pericardial effusion, and another video showing the actual drainage of this effusion.
His hospital course included the development of reactive pericarditis from the drain, but he left the hospital within a week.
Video 1: CT chest prior to pericardiocentesis – performed to rule out aortic dissection.
Note the large pericardial effusion
Video 2: Bedside echo showing large pericardial effusion (apical window)
Video 3: Echo-guided pericardiocentesis by portable phone camera during the procedure
Video 4: CT chest post-pericardiocentesis: minimal pericardial effusion noted
Pearls/Pitfalls related to US-guided pericardiocentesis:
- Although there are no absolute contraindications to perform bedside US-guided pericardiocentesis, it is preferable that hemodynamically stable patients with large pericardial effusions be drained in the operating room with the most experienced personnel.
- Pericardiocentesis without US guidance can put the patient at risk for injury to the liver, cardiac chambers, arteries (internal mammary, intercostal, coronaries), stomach, bowel and lung. US guidance can help to reduce these risks.
- Choose the cardiac window for pericardiocentesis that has the largest, most superficial pocket of fluid, avoiding overlying organs that may obstruct needle path (liver, lung)
- Determine the depth of pericardial effusion using the markers on the side of the ultrasound screen. A spinal needle may be required to reach pericardial space.
- For the subxiphoid approach, place curved or phased array probe caudal to the xiphoid process. For apical or parasternal window approach, switching to the high-frequency probe can provide better visualization of the needle as it advances into the pericardial sac.
- Don’t be misled into mistaking large anterior pericardial fat pads for effusions. Significant effusions will be circumferential, not just anterior.
Date: 2015