Chapter 19: Procedures and Skills

CARDIOTHORACIC PROCEDURES

Pericardiocentesis

INDICATIONS

• Hemopericardium

• Pericardial effusion with tamponade

• Pneumopericardium

CONTRAINDICATIONS

• Relative: Coagulopathy, implanted devices and/or valves, ascending aortic dissection, immediately available definitive treatment modalities

TECHNIQUE

• Use ultrasound guidance when available to identify greatest fluid collection.

• Cardiac monitoring with defibrillator, advanced airway and resuscitation equipment should be readily available.

• Attach a 7.5- to 12.5-cm 18-ga needle or Intracath needle to a syringe. Continuously aspirate syringe while advancing needle.

• Parasternal approach:

• Insert needle perpendicular to the skin in the left fifth or sixth intercostal space 1 cm lateral to the sternum.

• Avoid area of internal mammary artery, which lies 3-5 cm from the sternal border.

• Subxyphoid approach:

• Insert needle 1 cm inferior to the junction of the xyphoid process and left costal margin at a 30°-45° angle to the skin aiming toward the left shoulder (Figure 19.1).

• An ECG lead attached to the needle will show a current of injury (wide complex with ST elevation) when the needle touches the ventricular wall. When this occurs, withdraw the needle until the injury pattern is no longer present.

• Needle will penetrate the pericardium about 6-8 cm beneath the skin in adults and < 5 cm in children.

• Post-procedure: Obtain chest x-ray (CXR) to evaluate for pneumothorax or pneumoperitoneum.

COMPLICATIONS

• Failure to yield fluid (“dry tap”), often caused by clotted blood or a skin plug.

• Myocardial injury leading to hemopericardium.

• Coronary vessel laceration leading to myocardial infarction and/or hemopericardium.

• Internal mammary artery laceration leading to hemothorax.

• Pneumothorax/pneumoperitoneum.

INTERPRETATION OF RESULTS

• Removal of 30-50 mL may result in marked clinical improvement.

• Except in aortic dissection or ventricular wall rupture, pericardial fluid should have a lower hematocrit than venous blood, otherwise suspect that the needle has entered a cardiac chamber.

• Injection of a small amount of contrast under fluoroscopy can disclose intracardiac placement.

Thoracostomy

INDICATIONS

• Needle thoracostomy:

  • Emergent decompression for temporary treatment of tension pneumothorax

• Tube thoracostomy:

  • Treatment of ...