I asked Dr. Steuerwald if he wanted to write a blog post on pericardiocentesis. He responded with this:
“Pericardiocentesis is stupid…
Do a clamshell instead”
Not exactly what I was expecting in response, but it does bring up a couple of interesting points..
First, pericardiocentesis should be considered a temporizing procedure. In the setting of trauma, you are hoping that the pericardiocentesis will clear a small amount of blood from the pericardial space and remove any tamponade the might be present. It is likely, however, because of the mechanism of injury, that blood will again rapidly accumulate leading to recurrent tamponade physiology. Ultimately (but not on Air Care — DON’T do a clamshell), these patients will need a pericardial window, exploration, and repair of whatever injury is causing the accumulation of blood. Pericardiocentesis has fallen out of favor as a standard procedure in the evaluation of the traumatic arrest patient as it has been replaced by the use of ultrasound to evaluate for the presence of pericardial effusion. (Hey, we have one of those on the helicopter!)
The second interesting point brought up by Dr. Steuerwald’s rebuff is more of a question than a point. Will HEMS services be doing (rigorously protocoled) clamshell thoracotomies in the field in the future? Potentially. (but there are going to be significant hurdles to the field implementation of such a procedure)
Outside of trauma, there are a couple of scenarios in which the performance of a pericardiocentesis may be needed. If a patient is being transferred for definitive treatment of pericardial tamponade (think cardiac patients or patients with metastatic cancer and pericardial effusion) from an outside hospital, one would expect that a pericardocentesis had already been performed, and a drain placed. However, this is not necessarily the case depending on the resources of the outlying hospital. In addition, a pericardial drain could malfunction or could become dislodged in transport, necessitating repeat performance of the procedure
Let’s take a look at how to perform a pericardiocentesis with our 2-part video series.