Rachel C. Frank
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1. A 39-year-old woman presents to the Emergency Department 12 hours after the onset of rhinorrhea, nasal congestion, and cough. She reports pleuritic chest pain, shortness of breath, and light-headedness. Her electrocardiogram (ECG) reveals sinus tachycardia with low voltage and electrical alternans. Her HR is 124 bpm, and BP is 88/66 mm Hg, with pulsus paradoxus of 15 mm Hg.
A still image from her echocardiogram is shown in Figure 77.1.
Which of the following pericardial effusions can be most safely drained via pericardiocentesis?
A. Effusion due to pericarditis measuring 22 mm in diastole adjacent to the right ventricular free wall
B. Effusion due to aortic dissection or myocardial rupture
C. Effusion in a patient with severe pulmonary hypertension
D. Organized pericardial hematoma
1. Correct Answer: A. Effusion due to pericarditis measuring 22 mm in diastole adjacent to the right ventricular free wall
Rationale: An effusion measuring 22 mm in diastole is large, and it would be safe to perform echocardiography-guided pericardiocentesis. Effusions that are the result of aortic dissection or myocardial rupture are a surgical emergency. In these cases, pericardiocentesis may delay definitive surgical intervention or exacerbate bleeding. In severe pulmonary hypertension (right ventricular systolic pressure > 70 mm Hg), the right ventricular free wall may be splinted by the effusion and rapid draining of the effusion may result in worsening tricuspid regurgitation and right ventricular failure. However, the benefits of pericardiocentesis for a patient with tamponade (even when concomitant pulmonary hypertension is present) outweigh the risks of worsening right ventricular function. Nevertheless, caution should be taken to ensure that the effusion is not drained completely. Organized pericardial hematomas (particularly those following cardiac surgery) may not be easily drained by pericardiocentesis. These effusions are optimally managed with surgical intervention.
1. De Carlini CC, Maggiolini S. Pericardiocentesis in cardiac tamponade: indications and practical aspects. E-Journal Cardiol Pract. 2017;15(19). Available online www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Pericardiocentesis-in-cardiac-tamponade-indications-and-practical-aspects.
2. A 74-year-old man is admitted to the post-anesthesia care unit (PACU) following placement of a permanent pacemaker. His medical history includes sinus node dysfunction, hypertension, diabetes, and chronic kidney disease requiring hemodialysis. Four hours later, he develops shortness of breath, and his vital signs are notable for a HR of 125 bpm and a BP of 82/68 mm Hg. Cardiac ultrasound is quickly performed, and a large pericardial effusion is visualized.
Which of the following steps can be performed to increase the safety of echocardiography-guided pericardiocentesis?
A. Checking platelet count, partial thromboplastin time (PTT) and prothrombin time (PT)/international normalized ratio (INR)
B. Injecting 5 mL of agitated saline to confirm entry into the pericardial space
C. Obtaining echocardiographic images to confirm size, location of pericardial effusion, and trajectory of optimal entry
D. All of the above
2. Correct Answer: D. All of the above
Rationale: Echocardiography-guided pericardiocentesis can increase the safety of emergency pericardiocentesis. This includes obtaining images in different planes to identify the largest effusion diameter in a location amenable to drainage. Additional steps can be taken by the medical team to increase the safety of the procedure. Optimally, in patients undergoing this procedure, identification and reversal of coagulopathy would take place prior to intervention, provided that the patient is stable enough to wait for laboratory data to return. In nonemergent procedures, cross-matched packed red blood cells should also be available in case of a bleeding complication. Once the pericardial fluid has been aspirated and the needle removed, injecting 5 mL of agitated saline through the sheath into the pericardial space confirms entry into the pericardial space. This is an important safety check prior to dilation. Bubbles should be seen in the pericardial space and not in the ventricles or atria of the heart.
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