PeriCardio Sintesis

Ultrasound Guided Pericardiocentesis
Adi Osman
Senior Consultant Emergency Medicine & ED Critical Care
Trauma & Emergency Department,
Hospital Raja Permaisuri Bainun, Ipoh
Perak, Malaysia
Board of Director , WINFOCUS World Fed
Editor,
Critical Ultrasound Journal . Springer Open.
osman.adi@gmail.com
Translating Vision Into Reality

www.criticalultrasoundmalaysia.org
Translating Vision Into

Reality
Basic Haemodynamic: FoCUS in Undifferentiated Shock & DVT
CARDIAC TAMPONADE
Clinical Diagnosis & Supported by echo

findings
• Effusion
RV Diastolic Collapse RA Systolic Collapse • RV diastolic collapse
• RA systolic collapse
• Systemic venous congestion
• “swinging heart” (may suggest)
Systemic Venous Swinging Heart Roy C. JAMA 2007

Congestion

Reality
Acute VS Chronic Pericardial Eﬀusion
Chronic Pericardial Effusion
Acute Pericardial Effusion

Reality
Pericardial Effusion VS Pleural Effusion
Pericardial Effusion
Dec Aorta
Pleural Effusion

Reality
Old Technique / Blind Subxiphoid
EF Reichman. McGraw Hill 2003 Spodik DH, NEJM 2003

Reality
Old Technique / Blind Subxiphoid
! Success Rate 86%

! Mortality 4%
! Major Complications
4%
Krikorian JG. Am Med J 1978

Reality
Pericardiocentesis - complications
! Heart
• Ventricular fibrillation
• Ventricular lacerations (bleeding)
• Coronary artery injury (post CABG)
! Thorax
• Pneumothorax
• Esophageal perforations
• Mediastinitis
• Upper abdominal organ injury

Reality
Teresa S M Tsang; William K Freeman; Lawrence J Sinak; James B Seward
Mayo Clinic Proceedings; Jul 1998; 73, 7; ProQuest Medical Library

pg. 647

Reality
ULTRASOUND GUIDED PERICARDIOCENTESIS
Pericardiocentesis Sites
Apical approach

Reality
! Site: • Largest fluid amount

• Closest to probe
• Avoiding vital structures
! Central venous' line kit, spinal needle,
Pneumocath or venflon (no steel needle)
! Confirmation
1. Injection of saline ± agitated with air!
2. Color Doppler
US-guided technique (Class IIa by ACC) , TS Tsang. Mayo Clin Proc.1998;73:647-53

Reality
Pericardiocentesis - equipment
! Pericardial puncture set
! 6 – 10 French central venous line kit

! Spinal needle
! Pneumocath
! Pigtail catheter

Reality
How To Perform
Prepare the patient and assemble the necessary equipment.
Using ultrasound, determine the presence and distribution of pericardial fluid.

Systematically examine the heart and look for effusions at each imaging window (subcostal,
parasternal, apical, and any additional views).
Select the best entry site. This site contains the largest pericardial fluid accumulation that is
closest to the chest wall and can be entered without puncturing any adjacent vital organs.
Patient repositioning (eg, reverse Trendelenburg) may redistribute pericardial fluid and
affect the target window.
Relevant vascular structures to avoid, such as the internal mammary arteries, can be
located during this evaluation.Select a target fluid layer (distance from pericardium to
epicardium) of at least 1 cm to avoid cardiac puncture. Ultrasound does not pass through
air so the lung is avoided if the needle trajectory mirrors the approach delineated by
ultrasound.

Reality
Apical Approach
The apical pericardiocentesis approach reduces the risk of cardiac

complications by taking advantage of the proximity to the thick walled left
ventricle and the small apical coronary vessels.
However, proximity to the left pleural space increases the risk for
pneumothoraxInjuries associated with percutaneous placement of
transthoracic pacemakers.
Brown CG, Gurley HT, Hutchins GM, MacKenzie EJ, White JD
Ann Emerg Med. 1985;14(3):223.
The apical insertion site is at least 5 cm lateral to the parasternal approach

within the fifth, sixth, or seventh intercostal space. Advance the needle over
the cephalad border of the rib and towards the patient's right shoulder.

Reality
Apical Approach
However, proximity to the left pleural space increases the risk for
pneumothoraxInjuries associated with percutaneous placement of
transthoracic pacemakers.
Brown CG, Gurley HT, Hutchins GM, MacKenzie EJ, White JD
Ann Emerg Med. 1985;14(3):223.

Reality
Apical Approach
Client 1 Client 2
19 y.o boy admitted

to ICU with Acute
Viral
Myocarditis ,noted
Pericardial
Tamponade
Referred case (Failed

Pericardiocentesis ) from Army
Hospital ,Lumut
27 y.o , Female , SLE with
Pericardial Tamponade secondary
to Pericarditis.
Courtesy of Dr. Adi Osman , Dr Suhailan Malaysia
Courtesy of Dr. Adi Osman , Dr Azma Haryaty and
Dr Foong Kit Weng, Malaysia

Reality
Subcostal Approach
The extrapleural subcostal pericardiocentesis approach is performed as follows:Introduce the needle
substernally 1 cm inferior to the left xiphocostal angle.
Once beneath the cartilage cage, lower the needle so it approximates a 15 to 30 degree angle with
the abdominal wall.Aim the needle toward the left shoulder and advance it slowly while continuously
aspirating.
If no fluid is aspirated, the needle should be withdrawn promptly and redirected. In the absence of
ultrasound guidance, withdraw the needle to the skin and redirect it along a deeper posterior
trajectory.
The required depth of insertion is affected by the patient's anatomy. In most cases, a 7 to 9 cm needle
is adequate, but longer needles (up to 12 cm) may be needed for obese patients. In infants and small
children, 4 cm (1.5 inch) needles are sufficient.
If no fluid is aspirated on the second attempt, withdraw the needle to the skin and redirect it 15
degrees to the patient's right of the last dry needle path. Perform systematic redirected aspirations by
working from the patient's left to right until the needle is aimed toward the right shoulder.
Ultrasound guidance generally enables the clinician to avoid inserting the needle into other organs.
However, interposition of the left liver lobe is often recognized on subcostal imaging and the lobe may
be traversed intentionally during pericardiocentesis, if an alternative site is not available.

Reality
Subcostal Approach
Courtesy Adi Osman , Hamizah & Azma -Malaysia

Reality
Parasternal Approach
Lung ( Lat to Medial
Adi Osman , Julina MN , M Fadly Yahya -Malaysia

Reality

Reality

Reality
Catheter Tip Confirmation : Guidewire Insertion

Reality
Catheter Tip Confirmation : Nacl -Air Microbubble
• Two 5ml syringes

• 3 way stopcock
• 4.5 ml saline
• 0,5 ml air

Reality
Catheter Tip Confirmation : Nacl -Air Microbubble
• Two 5ml syringes

• 3 way stopcock
• 4.5 ml saline
• 0,5 ml air
“Rocket Flare”

Reality
Catheter Tip Confirmation : CXR

Reality
c Pericardial Tamponade
35 y.o stabbed with screwdriver on L upper chest ,
hypotensive in ambulance , intubated on the scene and
fluid resus en route . Pulseless arrest upon ED arrival.
The Way To a Man’s

Heart is through A Left
Anterolateral
Thoracotomy
Courtesy of Adi Osman and Ruth Sabrina, Malaysia

Reality
ricardial Tamponade Traumatic Myocardial Injury 2” to Sternal
Fracture presented with Pericardial Temponade

Reality
The future PoCUS in Critical Care / Emergency Medicine
TEE in Resuscitation / Guided Procedures
AMERICAN SOCIETY OF ECHOCARDIOGRAPHY CONSENSUS STATEMENT
Focused Cardiac Ultrasound in the Emergent Setting:

A Consensus Statement of the American Society of
Echocardiography and American College of
Emergency Physicians
Arthur J. Labovitz, MD, FASE, Chair,* Vicki E. Noble, MD, FACEP,** Michelle Bierig, MPH, RDCS, FASE,*
Steven A. Goldstein, MD,* Robert Jones, DO, FACEP,** Smadar Kort, MD, FASE,*
Thomas R. Porter, MD, FASE,* Kirk T. Spencer, MD, FASE,* Vivek S. Tayal, MD, FACEP,**
and Kevin Wei, MD,* St. Louis, Missouri; Boston, Massachusetts; Washington, District of Columbia; Cleveland, Ohio;
Stony Brook, New York; Omaha, Nebraska; Chicago, Illinois; Charlotte, North Carolina; Portland, Oregon
The use of ultrasound has developed over the last 50 years into an indispensable first-line test for the cardiac
evaluation of symptomatic patients. The technologic miniaturization and improvement in transducer technology,
as well as the implementation of educational curriculum changes in residency training programs and specialty
practice, have facilitated the integration of focused cardiac ultrasound into practice by specialties such as
emergency medicine. In the emergency department, focused cardiac ultrasound has become a fundamental
tool to expedite the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and
triage decisions by the emergency physician. (J Am Soc Echocardiogr 2010;23:1225-30.)
Keywords: Echocardiography, Emergency department, Focused cardiac ultrasound, Resuscitation
This consensus statement by the American Society of Echocardiography ectopic pregnancy, or intraperitoneal hemorrhage as a result of trauma),
(ASE) and the American College of Emergency Physicians (ACEP) the scope of this consensus statement is limited to cardiac applications
delineates the important role of focused cardiac ultrasound (FOCUS) of the FOCUS examination. Accordingly, the important role of compre-
in patient care and treatment and emphasizes the complementary hensive transthoracic echocardiography and transesophageal echocar-
role of FOCUS to that of comprehensive echocardiography. We outline diography in the emergency department will not be discussed in
the clinical applications where FOCUS could be used, as part of the detail in this article.
evolving relationship between echocardiography laboratories and emer-
gency departments. Although cardiac ultrasound as performed by FOCUSED CARDIAC ULTRASOUND VERSUS
emergency physicians in emergency departments is often performed COMPREHENSIVE ECHOCARDIOGRAPHY
in the context of other focused ultrasound applications (examining
the hypotensive patient for abdominal aortic aneurysms, ruptured The principal role for FOCUS is the time-sensitive assessment of the
symptomatic patient.1-5 This evaluation primarily includes the
From the St. Louis University School of Medicine, St. Louis, Missouri (A.J.L., M.B.); assessment for pericardial effusion and the evaluation of relative
Massachusetts General Hospital, Boston, Massachusetts (V.E.N.); Washington chamber size, global cardiac function, and patient volume status
Hospital Center, Washington, District of Columbia (S.A.G.); MetroHealth Medical (Table 1). Intravascular volume status may be assessed by left ventric-
Center, Cleveland, Ohio (R.J.); Stony Brook University Medical Center, Stony
ular (LV) size, ventricular function, and inferior vena cava (IVC) size
Brook, New York (S.K.); University of Nebraska Medical Center, Omaha,
and respiratory change. In addition, FOCUS is used to guide emer-
Nebraska (T.R.P.); University of Chicago Medical Center, Chicago, Illinois
(K.T.S.); Carolinas Medical Center, Charlotte North Carolina (V.S.T.); and Oregon
gent invasive procedures, such as pericardiocentesis, or evaluate the
Health & Science University, Portland, Oregon (K.W.). position of transvenous pacemaker placement.3,5
Disclosures/Conflict of Interest: The following authors report a relationship with one
Other pathologic diagnoses (intracardiac masses, LV thrombus,
or more commercial interests: Thomas R. Porter, MD, FASE, serves as a consultant valvular dysfunction, regional wall motion abnormalities, endocarditis,
for Lantheus Medical Imaging, receives research support from Siemens Medical, aortic dissection) may be suspected on FOCUS, but additional
and receives grant support from Lantheus Medical Imaging, NuVox Pharma, and evaluation, including referral for comprehensive echocardiography or
Astellas Pharma, Inc. Vivek S. Tayal, MD, FACEP, receives research support cardiology consultation, is recommended. Further hemodynamic
from Philips Ultrasound. Kevin Wei, MD, receives grant support from Zonare and assessment of intracardiac pressures, valvular pathology, and diastolic
Philips Ultrasound. All other authors reported no actual or potential conflicts of function requires additional training in comprehensive echocardiogra-
interest in relation to this document. phy techniques.
Reprint requests: American Society of Echocardiography, 2100 Gateway Centre Comprehensive echocardiographic examination or other imaging
Boulevard, Suite 310, Morrisville, NC 27560 (ase@asecho.org). modalities are recommended in any case in which the focused find-
* American Society of Echocardiography and ** American College of Emergency ings and clinical presentations are discordant. Clinical scenarios and
Physicians. the information obtained from the focused use of cardiac ultrasound
0894-7317/$36.00 in emergent situations are distinctly different from those where
Copyright 2010 by the American Society of Echocardiography. comprehensive echocardiography are used, and both types of studies
doi:10.1016/j.echo.2010.10.005 have a role in optimizing patient care as will be outlined in the
1225
Peeping Into Septic Heart and Lung

Reality
Resuscitative TEE in ED
LA
LV
RV
LA
Ao
LV
CPR Check
Heart during pulse check
LA
LA
LV LV
RV RV
CPR Check
PA
PA
Ao
Early Diagnosis-PE
Early Diagnosis-TAI
Reality

PeriCardio Sintesis

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

PeriCardio Sintesis

Загружено:

Авторское право:

Доступные форматы

Ultrasound Guided Pericardiocentesis

Board of Director , WINFOCUS World Fed

Translating Vision Into Reality

Translating Vision Into

Clinical Diagnosis & Supported by echo

RV Diastolic Collapse RA Systolic Collapse • RV diastolic collapse

• Systemic venous congestion

• “swinging heart” (may suggest)

Systemic Venous Swinging Heart Roy C. JAMA 2007

Translating Vision Into

Acute VS Chronic Pericardial Eﬀusion

Chronic Pericardial Effusion

Acute Pericardial Effusion

Translating Vision Into

Pericardial Effusion VS Pleural Effusion

Translating Vision Into

Old Technique / Blind Subxiphoid

EF Reichman. McGraw Hill 2003 Spodik DH, NEJM 2003

Translating Vision Into

Old Technique / Blind Subxiphoid

! Success Rate 86%

Krikorian JG. Am Med J 1978

Translating Vision Into

Translating Vision Into

Ultrasound Guided Pericardiocentesis

Translating Vision Into

ULTRASOUND GUIDED PERICARDIOCENTESIS

Translating Vision Into

! Site: • Largest fluid amount

Translating Vision Into

! 6 – 10 French central venous line kit

Translating Vision Into

Using ultrasound, determine the presence and distribution of pericardial fluid.

Translating Vision Into

The apical pericardiocentesis approach reduces the risk of cardiac

The apical insertion site is at least 5 cm lateral to the parasternal approach

Translating Vision Into

Translating Vision Into

19 y.o boy admitted

Referred case (Failed

Translating Vision Into

Translating Vision Into

Courtesy Adi Osman , Hamizah & Azma -Malaysia

Translating Vision Into

Lung ( Lat to Medial

Adi Osman , Julina MN , M Fadly Yahya -Malaysia

Translating Vision Into

Translating Vision Into

Translating Vision Into

Catheter Tip Confirmation : Guidewire Insertion

Translating Vision Into

Catheter Tip Confirmation : Nacl -Air Microbubble

• Two 5ml syringes

Translating Vision Into

Catheter Tip Confirmation : Nacl -Air Microbubble

• Two 5ml syringes

Translating Vision Into

Catheter Tip Confirmation : CXR

Translating Vision Into

The Way To a Man’s

Translating Vision Into

Translating Vision Into

Focused Cardiac Ultrasound in the Emergent Setting:

Keywords: Echocardiography, Emergency department, Focused cardiac ultrasound, Resuscitation