1. Rapid Clinical Assesment
- ABCDE Approach
- Monitoring and Oxygenation:
- Put on high flow mask
- Maintain SpO₂ > 95%.
- Place the patient on a cardiac monitor.
- Establish intravenous (IV) access.
2. Identification
Beck's Triad:
- Muffled Heart Sounds
- Hypotension
- Distended Neck Veins
Additional Signs:
- Tachycardia:
- Rapid heart rate as compensatory mechanism.
- Pulsus Paradoxus:
- Exaggerated decrease in systolic blood pressure during inspiration.
- Elevated Central Venous Pressure (CVP):
- Indicating increased intrapericardial pressure.
Ultrasound Findings:
In sequential order
i. RA systolic collapse:
- Seen as inward denting with the tricuspid valve remains closed.
ii. Plethoric IVC:
- <50% collapsibility
- Diameter >2.1 cm
iii. RV diastolic collapse:
- Seen as inward denting during filling (mitral/tricuspid valve open).
iv. MV/TV flow variation:
- Mitral flow variation >30%
- Tricuspid flow variation >60%
v. Large pericardial effusion with a swinging heart.
3. Immediate Intervention
A. Definitive Airway:
- Secure airway with endotracheal intubation.
B. Emergent pericardiocentesis
Procedure:
i. Position the patient:
- Semirecumbent, 30 degrees head-up, slightly rotated leftward. (if possible)
ii. Identify the site of entry:
Subxiphoid:
- Insertion: Between the xiphisternum and left costal margin.
- Method: Lower the needle to a 15-to-30-degree angle, directed towards the left shoulder.
- Advantages: Lower risk of pneumothorax.
- Disadvantages: Risk of right atrial or liver puncture; longer pathway.
Parasternal
- Insertion: 5th ICS close to the sternal margin.
- Method: Perpendicular needle insertion at the cardiac notch of the left lung.
- Advantages: Good echocardiographic visualization.
- Disadvantages: Risk of pneumothorax or puncture of internal thoracic vessels.
Apical:
- Insertion: 1-2 cm lateral to the apex beat (5th, 6th, or 7th ICS).
- Method: Insert the needle over the superior border of the rib.
- Advantages: Shorter path, thicker left ventricular wall (more likely to self-seal after puncture).
- Disadvantages: Risk of ventricular puncture or pneumothorax.
iii. Prepare the area:
- Clean the site with antiseptic.
- Provide local anesthesia at the entry point.
iv. Needle insertion & location confirmation:
- Use a 16-18G needle and insert it above the nearest rib (for parasternal & apical approaches) under ultrasound guidance.
- Aspirate continuously during insertion and stop once the needle tip is visualized inside the pericardium.
- If unsure whether the needle is in the pericardium or ventricle, inject agitated saline with ultrasound to confirm.
v. Drainage:
- Drain only enough pericardial blood collection to normalize systemic blood pressure, not exceeding 1L.
- Watch out for pericardial decompression syndrome.
C. Surgical Intervention:
- If pericardiocentesis is unsuccessful or in cases of penetrating trauma.