TABLE 519 Echocardiographic Findings in Cardiac Tamponade

TREATMENT AND DISPOSITION Volume expansion with a bolus of normal saline solution (500 to 1000 mL) will increase intravascular volume, facilitate right heart filling, and increase cardiac output and arterial pressure. However, it is a temporary measure, and patients will require pericardiocentesis as initial definitive therapy and for diagnostic evaluation.

Pericardiocentesis should be performed under optimal circumstances, usually within the cardiac catheterization laboratory using echocardiographic guidance. The major potential complications, namely, cardiac perforation and coronary artery laceration, can be minimized. In addition, a pigtail catheter can be inserted to allow continuous fluid drainage and prevention of fluid accumulation.

Pericardiocentesis must be performed within the emergency department if dictated by hemodynamic instability. The subxiphoid approach with the patient sitting at a 45° angle is the preferred technique. A 16- to 18-gauge spinal needle is inserted between the xiphoid process and the left costal margin at a 30 to 40° angle to the skin. The needle is directed toward the right shoulder and continuous negative pressure applied to the syringe until fluid is withdrawn. Due to the shape of the pericardial volume-pressure curve, removal of only a small volume of fluid (e.g., 50 mL) can result in dramatic hemodynamic improvement. If time permits and the equipment is available, the V lead of an ECG monitor electrode can be attached to the needle using an alligator clip or Harrison adapter to detect epicardial contact (ST-segment elevation) as the needle is advanced beneath the skin.

If the equipment is available, echocardiographically guided emergency pericardiocentesis can be performed in the emergency department. Definitive management (insertion of an intrapericardial pigtail catheter through a pericardial window) is best undertaken following admission. After pericardiocentesis, patients require admission in a monitored setting.

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