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Procedural Skills (SLO6)
Question 45 of 127
A 21 year old man is brought to ED having been involved in a road traffic accident. He is hypotensive with muffled heart sounds and distended neck veins. Your consultant suspects cardiac tamponade and proceeds to perform emergency pericardiocentesis. You are monitoring the ECG trace during the procedure and note new ST elevation appears as the needle is inserted. What is the most appropriate immediate management step?
Answer:
- If the needle is advanced too far (i.e. into ventricular muscle), an injury pattern appears on the ECG (e.g. extreme ST-T wave changes or widened and enlarged QRS complex), indicating the needle should be withdrawn until the previous baseline ECG tracing reappears
- During the aspiration, the epicardium approaches the inner pericardial surface again, as does the needle tip, and the ECG injury pattern may reappear
- This indicates the needle should be withdrawn slightly
- Should this injury pattern persist, the needle should be withdrawn completely
Needle Pericardiocentesis
Procedural Skills (SLO6)
Last Updated: 2nd March 2021
Indications
- Pericardial effusion
- Cardiac tamponade
Procedure
- Monitor the patient's vital signs and ECG before, during, and after the procedure
- Use ultrasound to identify the effusion (ideally)
- Surgically prepare the xiphoid and subxiphoid areas, if time allows
- Locally anaesthetise the puncture site, if necessary
- Assess the patient for any mediastinal shift that may have caused the heart to shift significantly
- Use a 16- to 18-gauge, 6 inch (15 cm) or longer over-the-needle catheter attached to a 35/mL empty syringe with a three-way stopcock
- Puncture the skin 1 - 2 cm inferior to the left of the xiphochondral junction, at a 45-degree angle to the skin
- Carefully advance the needle cephalad and aim towards the tip of the left scapula; follow the needle with the ultrasound
- Advance the catheter over the needle; remove the needle
- When the needle tip enters the blood-filled pericardial sac, withdraw as much non-clotted blood as possible
- If the needle is advanced too far (i.e. into ventricular muscle), an injury pattern appears on the ECG (e.g. extreme ST-T wave changes or widened and enlarged QRS complex), indicating the needle should be withdrawn until the previous baseline ECG tracing reappears
- During the aspiration, the epicardium approaches the inner pericardial surface again, as does the needle tip, and the ECG injury pattern may reappear
- This indicates the needle should be withdrawn slightly
- Should this injury pattern persist, the needle should be withdrawn completely
- Once aspiration is complete, remove the syringe and attach a three-way stopcock, leaving the stockcock closed; secure the catheter in place with suture or tape and cover with a dressing
- Should the tamponade symptoms persist or worsen, the three-way stopcock may be opened and the pericardial sac re-aspirated prior to definitive treatment enroute to surgery or transfer to another care facility
Complications
- Aspiration of ventricular blood instead of pericardial blood
- Laceration of ventricular epicardium or myocardium
- Laceration of coronary artery or vein
- Ventricular fibrillation
- Pneumothorax secondary to lung puncture
- Puncture of great vessel with worsening of tamponade
- Puncture of oesophagus with subsequent mediastinitis
- Puncture of peritoneum with subsequent peritonitis
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
