Nightmares continued... Pericardiocentesis edition

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A little fun fact about me is that I frequently wake up at 3, 4 or 5 in the morning in a cold sweat from some sort of vivid nightmare. The nightmares can vary from having a hot pink wedding dress that doesnt fit me, to having to do a pericardiocentesis on a patient who is wide awake asking me if I have ever performed one before, as he is actively tamponading in front of me. I figured I would do a short series of deep diving as a way to soothe my own anxieties in an effort to get better sleep, so without further ado, lets take a look at pericardiocentesis.  


Now I had weeks of nightmares, followed by a sim session on pericardiocentesis before I came face to face with a real one.I had the great fortune of working a Northside shift with the wonderful Dr. Errel Khordipour- who if you didn't know is the local pericardiocentesis expert. The man has done probably 600 at this point, (I am kidding- I think its closer to 30? Cue Errel rolling his eyes), and as the story goes, I was being a nosey nancy and once again butted my way into the resus bay- this time with Dr. Mark Calandra when Mark expertly intubated a gentleman who was boarding in the ED who decompensated on the wall. The patient shortly after being intubated, coded.  While we were doing compressions, Errel did what he does best- threw a probe on this mans chest to find a large pericardiocentesis and well there you have it, the mans 1000th pericardiocentesis. 


Pericardiocentesis: 

  • Indication: Pericardial effusion which is an accumulation of fluid between the visceral and parietal layers of the pericardium, this can reduce the heart's ability to fill or empty appropriately 

  • Cardiac Tamponade: when the fluid accumulation occurs so quickly there is significant impairment of the filling of the right ventricle 

    • This requires an emergent or urgent procedure and consider performing in the ED 

    • Confirm on ultrasound which should present with: 

      • Right atrial collapse > ⅓ 

      • Early right ventricular diastolic collapse

  • Can be done Emergently or Urgently

    • Emergent: patient is in cardiac arrest or peri arrest and there are no other sources for the patients instability 

    • Urgently: consider the etiology of the pericardial effusion (infections, reactive, related to fluid overload)

  • Performing the procedure: 

    • Can be done blind or ultrasound guided

    • Blind: 

      • Use a subxiphoid approach 

      • Clean the area, consider local anesthetic if the patient is not in cardiac arrest 

      • Using an 18 gauge spinal needle on a 20 cc syringe, insert the needle 1 cm between the left costal arch and xiphoid process

      • Angle the needle at ~20 degrees pointed towards the left shoulder, slowly advancing while withdrawing on the plunger 

      • Aspirate enough fluid to allow for clinical improvement 

    • Ultrasound guided: 

      • Using the ultrasound to find the largest window with effusion

      • Insert the needle in the plane with the largest window

      • With ultrasound you have the freedom to do this subxiphoid, apical, suprasternal, or parasternal 

      • Walk the tip of the needle with the ultrasound 

      • Once inside the pericardial window, you can remove the syringe and using Seldingers technique, thread a wire into this space, followed by a dilator, and then a pigtail catheter, allowing more continuous drainage from this effusion

  • Complications to consider: 

    • My greatest fear is always that I spear the ventricle and essentially create a pigtail into the ventricle that I just pour blood from the ventricle out into the world 

    • Other fears to add onto this include hitting other large vessels (mammary arteries, intercostal arteries), causing a pneumothorax, liver or peritoneal injuries, infection or death

  • If you are performing a pericardiocentesis in the ED, these patients have an extremely high mortality rate, however this can be a lifesaving measure that could potentially change the outcome for your patient


So I will leave us there, but now you will be better prepared the next time your unstable, chest pain patient decompensates on the wall to grab the spinal needle and perform a pericardiocentesis and save your patient's life! 



Until next time! Sweet Dreams!


Your admin resident,
Kaitlyn 


References; 

Tewelde S. Pericardiocentesis. In: Swadron S, Nordt S, Mattu A, and Johnson W, eds. CorePendium. 5th ed. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recWedjPB7rstCdug/Pericardiocentesis#h.hxonuesemkf2. Updated December 7, 2021. Accessed March 12, 2025.

Willner DA, Shams P, Grossman SA. Pericardiocentesis. [Updated 2025 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470347/

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Nightmare Fuel: Trachoestomy Emergencies

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Hi Everyone and Happy Tuesday!

I am here to officially introduce myself as this block’s Admin Resident! If we haven’t had the chance to meet- my name is Kaitlyn DeStefano, one of the third year residents and I have the misfortune of following the great Dan Ye, so though my POTDs will not nearly be as amazing, I will sure try. Without further delay, I want to tell you all about a case I was peripherally involved with this weekend, the wonder Dr. Mara Zafrina primarily saw and highlight some learning points I took away. 


Its Sunday afternoon, Palm Gardens has sent over its fifth trach to vent patient to Northside and we get the pre-notification for a stable trach to vent patient who’s chief complaint is bleeding from the trach. The patient arrives and EMS looks a bit panicked because- no no, this is not a stable patient, the patient is saturating in the 70s and had a little episode en route with some bradycardia though they adjusted the bag to the trach and it picked up but nonetheless, here they are standing in the hallway outside of 52. 


Before the patient even gets slotted into a location, Dr. Zafrina starts with listening to the lungs, “bilateral lung sounds” but also “feels like there is some subcutaneous air”. Okay- that’s weird. Also the patient’s face looks a bit swollen, but I dont know who this lady is- maybe thats normal for her, they get her into 52 and the show really gets started. 


The patient has saturations in the 60-70s. The patient has subcutaneous air extending around the chest into the face, eyelids, tongue, and around the mouth. The patient is starting to become more and brady with HRs dipping into the 30s and 20s. Yogi, the respiratory therapist helping us, is having a difficult time bagging the patient is meeting a lot of resistance and there is a ton of air coming from around the trach. Dr. Aghera attempts to re inflate the balloon, replace the trache bedside, once with inner cannula, once with a new trache and still the patients HR is in the 20s, we have no saturation on the monitor and the patient is becoming cyanotic. Desperate, I paged thoracic and begged for anyone to come help us. Dr. Zach Cohen replies, “get the bronch ready” and before we know it the surgical senior, junior, intern are all at bedside, shortly followed by Dr. Caifa. They drop the bronch- there are no tracheal rings, no carina. And also now, no pulse. ACLS is initiated. An airway is established from before with an endotracheal tube. ACLS continues, patient continues to be pulseless, and b/l chest tubes are placed, finally ROSC is achieved. 


Man- I knew to be scared of traches but I had NO idea how quickly this could go sour and how scared I would be in these moments even as a bystander. I thought I would do a deep dive into tracheostomies and how to troubleshoot. As good ED staff the hallmark to any unstable patients is to go back to the basics: 

  • Airway: 

    • Apply supplemental to both the mouth/nose AND the stoma 

      • Both can be done with a non rebreather

    • Determine the age of the tracheostomy and the patency of the airway above it 

      • In this patient’s case I did a quick chart check and could not see when the trache was placed but could see during the patient’s January admission she was on nasal cannula only so it was at most 2 months old 

    • If there is bleeding at the tracheostomy: Concern for tracheo-innominate artery fistula

      • Over inflate the balloon to tamponade the bleed OR

      • Apply direct pressure with your fingers at the site of the bleeding 

    • Tracheostomy obstruction: 

      • Common problem: Mucus plugging

        • Attempt to resolve with passing a flexible suction 

        • May need to remove the inner cannula and suction the outer cannula 

        • Attempt to ventilate when deflating the cuff

        • If unable to fix, remove the tracheostomy 

    • Tracheostomy Decannulation: Bingo! This was our problem

      • Occurs with partial or complete displacement 

      • Can assess for this by: 

        • Attempting to pass flexible suction

        • Connect end tidal to the tracheostomy

        • Attempt to pass a bronchoscopy for direct visualization 

      • You should start to suspect a false passage if subcutaneous emphysema occurs 

      • Establish a definitive airway through direct visualization either above the tracheostomy or through visually directed bronchoscopy 

  • Breathing: 

    • If bag valve mask ventilation is needed: 

      • Apply a bag mask valve over the mouth and nose and cover the tracheostomy stoma with a wet gauze  OR 

      • Apply a bag mask valve over the tracheostomy stoma and cover the mouth and nose 


In this patient, I suspect that the patient had such significant subcutaneous emphysema that was worsened by continued positive pressure ventilatory systems which increased high peak pressures, worsening barotrauma, and expanding pneumothoraces, to the point of causing cardiac arrest!  


And with that- I will leave you this nightmare fuel until we talk again! 

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VOTW: In the Thick of It

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HPI

A 40-year-old female with a PMH of polycystic kidney disease, HLD, and HTN presents with 1 month of episodic dizziness. She was referred to the ED by her cardiologist for an abnormal EKG, and had previously been told that she had an enlarged heart. 

Her vital signs are unremarkable. Physical exam is notable for a harsh, blowing systolic murmur. Chest X-ray shows cardiomegaly.

Ultrasound Findings

Point-of-care echocardiogram showed no pericardial effusion and was notable for septal thickening to 2.2 cm, concerning for hypertrophic obstructive cardiomyopathy (HOCM).

Echocardiography is the first-line imaging modality for the diagnosis of hypertrophic cardiomyopathy. 

Key findings are wall thickening and intraventricular obstruction. 

  • Wall thickening > 15 mm (or > 13 mm in patients with relatives diagnosed with HOCM). This can be measured in the parasternal long or short axis views. 

  • Interventricular septum to posterior wall thickness ratio of > 1.3 in normotensive patients or > 1.5 in patients with HTN

  • Thickening usually occurs on a focal region of the LV wall

Other associated findings include mitral valve abnormalities, systolic dysfunction, and diastolic dysfunction.

  • Systolic anterior motion of the mitral valve may occur in HOCM due to the Venturi effect. Septal hypertrophy narrows the LVOT, accelerating blood flow and creating a suction force that pulls the mitral valve leaflet into the LVOT. This causes outflow obstruction as well as mitral regurgitation. 

Case Conclusion

Based on these findings, the patient was placed in observation for cardiology evaluation. 

Comprehensive echocardiogram revealed findings consistent with HOCM, including severe asymmetric left ventricular hypertrophy, hyperdynamic LV systolic function (LVEF 76-80%), moderate (grade 2) LV diastolic dysfunction, LV outflow tract obstruction, moderate systolic anterior motion of the anterior leaflet of the mitral valve, and moderate mitral valve regurgitation.

The patient was newly diagnosed with and educated about HOCM. She was discharged with metoprolol 25 mg daily and is anticipated to undergo further treatment with mavacamten and possible septal reduction surgery. 

References & Further Reading

Happy scanning!