Pericardiocentesis

23.15 Pericardiocentesis

Ronald A. Dieckmann

Background

The pumping heart is extremely sensitive to rapid accumulation of pericardial fluid. Small amounts of fluid acutely increase intrapericardial pressure and may significantly impede venous return and cardiac output. Haemopericardium is the most common fluid collection – blood collects between the visceral and parietal pericardium after a penetrating injury in the high risk zone formed by the triangle of the two nipples and the sternal notch. The risk of death from a penetrating injury to the heart is higher from the haemopericardium than from direct injury to the myocardium, coronary arteries or cardiac valves.

The classical presentation of paediatric cardiac tamponade is a child with a penetrating anterior chest-wall injury who has distant heart sounds, neck vein distension and hypotension (Beck’s triad). However, because other blood loss may concurrently reduce central venous pressures, and because audible intensity of heart sounds may be difficult to distinguish in children, suspect tamponade in any child with a high-risk chest-wall penetration in the triangle, even tiny, with signs of a possible perfusion deficiency – tachycardia, poor skin colour or temperature, delayed capillary refill or diminished pulses.

In contrast to haemopericardium, slow fluid accumulation in the pericardium from other aetiologies, such as viral, bacterial or mycobacterial infection, or from immunological/collagen vascular disease or malignancy, has a minimal effect on cardiac function. The distensible pericardium readily accommodates slow fluid collections and the presentation of such patients often does not involve perfusion abnormalities. In this setting, needle pericardiocentesis is best accomplished with echocardiographic guidance.

Pericardiocentesis is a needle procedure for either life-saving decompression of acute cardiac tamponade, or for diagnostic evaluation of a non-emergent pericardial effusion. Rapid removal of acute haemopericardial fluid by needle pericardiocentesis is sometimes life saving. The decompression of the pericardium will temporarily restore myocardial performance in a perfusing patient, until reaccumulation occurs. Hence, needle pericardiocentesis is a temporising measure that precedes open surgical decompression. Sometimes, it is a heroic intervention in cardiopulmonary arrest. In non-emergent settings, an indwelling catheter may be necessary to prevent fluid reaccumulation. The procedure can be done with or without electrocardiographic or echocardiographic guidance, depending on the urgency of the clinical situation. Because the majority of needle pericardiocentesis procedures are performed on children in cardiopulmonary arrest, who have low probability of survival, the efficacy and safety of the procedure are poorly understood.

Indications

• Cardiac tamponade.

• Pericardial effusion of unknown aetiology.

Contraindications

• There are no contraindications in the child presenting emergently with shock or cardiopulmonary arrest and evidence of acute tamponade. If equipment and appropriate personnel are present, open thoracotomy may be preferred over needle pericardiocentesis.

• In the non-emergent situation, an uncorrected bleeding diathesis is a contraindication.

Tags: Textbook of Paediatric Emergency Medicine

Sep 7, 2016 | Posted by admin in EMERGENCY MEDICINE | Comments Off

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