Drain a Cardiac Tamponade

Cardiac tamponade occurs when the pericardial sac surrounding the heart fills with blood following an injury.

Because the sac is relatively rigid and not elastic, even small amounts of blood in the pericardial sac can have important effects on the heart. With increasing amounts of blood in the sac, the heart is compressed and its' ability to fill and pump adequate amounts of blood is impaired. This is called cardiac tamponade and is characterized by:

• Hypotension (shock)

• Elevated central venous pressure

• Distended neck veins

• Muffled heart sounds

Pericardiocentesis (withdrawal of fluid or blood from the pericardial sac) can be undertaken in these patients for both diagnosis and treatment. The goals of pericardiocentesis are to:

1. Remove enough blood from the pericardial sac to restore ventricular filling, and

2. Maintain ventricular function long enough that definitive repair of the injury can made.

The essential equipment for the procedure is a long needle with an attached catheter, attached to a syringe. A good choice for this is a 14 gauge, 6-inch Angiocath needle. Some IV tubing and a 3-way stopcock are used for continuing drainage once the catheter is placed inside the sac.

Continuous EKG monitoring should be employed, if available. In the event of arrythmia provoked by the pericardiocentesis, you would ordinarily want to discontinue the procedure.

It is best to perform this technique using the sterile techniques of sterile gloves, antiseptic prep, and surgical draping. If these are unavailable but there is an urgent (life and death) need for pericardiocentesis, proceed, doing the best you can with what you've got.

Insert the needle just to the left of the xyphoid process (in the notch between the lower edge of the ribs and the bottom of the breast bone. Aim the needle for the lower tip of the left shoulder blade. Once the needle is through the skin, apply continuous suction with the syringe so that when you enter the pericardial sac, you will know immediately because of the return of blood.

As soon as you get significant blood return:

• Hold the needle in place.

• Slide the catheter over the needle and into the pericardial sac.

• Withdraw the needle.

• Re-attach the syringe to the soft catheter, which is now solidly inside the pericardial sac.

• Evacuate as much pericardial blood as you can get out.

The physical status of the patient will usually improve immediately.

Remember that although you have temporarily helped the patient, the injury that lead to the cardiac tamponade is still present, will need repair, and may lead to reaccumulation of blood in the pericardial sac. For these reasons, it is a good idea to leave the soft catheter in place, attached to IV tubing and a 3-way stopcock, so you can easily withdraw more blood if the patient's clinical condition deteriorates.

There are numerous potential complications from this procedure, including traumatic injury to the heart, blood vessels or lung, as well as infection. However, in the right patient at the right time, pericardiocentesis can save a life long enough for definitive surgical care to occur.

Watch a video demonstrating this technique.

Clinical signs of tamponade include hypotension, distended neck veins, and muffled heart sounds Essential equipment includes a 6-inch, 14 guage needle with attached catheter. Continuous EKG monitoring, if available, should be used. Insertion site is just to the left of the xyphoid process. Insert at a 45 degree angle, aiming at the tip of the scapula As soon as blood is aspirated, slide the catheter forward over the needle and into the sac to avoid injuring the heart with the needle tip. After the needle is withdrawn, additional blood can be aspirated as needed clinically.

This section was developed from "Emergency Surgical Procedure: Pericardiocentesis" A1701-96-000138, Health Sciences Media Division, US Army Medical Department C&S, Fort Sam Houston, Texas

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