Cliff Read recently put out a great post on this issue.
The take home points:
- Perform when refractory shock with evidence of tamponade physiology on ECHO:
A large effusion with a ‘little invisible man using the RV as a trampoline”
- Remove only small volumes of blood at a time (e.g. 30mls), aiming for a SBP of 90 mmHg.
The danger is overshooting the BP, resulting in hypertension and extension of the dissection which can be fatal.
- Avoid intubation if possible until a surgeon is ready to cut – positive pressures lead to worsening tamponade physiology (although mitigated by pericardiocentesis).
- Other options include intubation under local anaesthesia, allow the patient to breathe spontaneously through the tube, or preloading with fluid, using cautious doses of induction agent, and ventilating with low pressures & zero PEEP.
- CPR is futile in arrested patient.
- CPR leads to lower MAP and diastolic pressures, therefore worsening coronary perfusion. Only relief of tamponade will provide a chance of recovery.
- Patients requiring transport should be accompanied by a clinician able to perform pericardiocentesis in the event of deterioration en route.
There are several approaches – subxiphoid, left parasternal, apical. Go where the most blood is.
If they arrest To intubate or not to intubate?
CPR or no CPR?
How to transfer – physician escort or just send in an ambulance on lights and sirens?