<臨床情境>
一位65歲女性，主訴為胸痛喘好幾天因為心包膜積液被從楊梅天成轉診至本院
檢傷Vital signs: T/P/R: 35.8/184/34, BP: 無法測量, E3V2M5 SpO2: 74%
外院CT看到Massive pericardial effusion with tamponade 因而轉診
打過一支Adenosine and then amiodarone 1PC, continuous drip
過去病史: Esophageal rupture s/p OP? ; DM; HTN
理學檢查: clear conscious; bilateral decreased breathing sound
Lab: WBC 15200; Hb 8.8; INR 2.4sec; Cr 1.75; CRP 249; Lact 143 BNP 2462
ABG PH 6.97 PCO2 24.1 HCO3 5.4
CXR and EKG:
Bedside echo: massive pericardial effusion, IVC no collapse > 50%
Impression:
1. Cardiac tamponade, s/p pericardiocentesis
2. Acute respiratory failure, s/p ETT+MV
3. Sepsis, focus undetermined
4. Acute kidney injury
5. Severe metabolic acidosis, favored lactate acidosis
Admit to MICU, but persistent shock even after pericardiocentesis
After reviewing her history (Previous hx of esophageal cancer s/p gastric tube and reconstruction, septic shock and purulent pericardial effusion, neo-esophagus pericardial fistula with pericarditis and septic shock is suspected. CVS was consulted and gastric tube take down then esophagostomy and jejunostomy was done. The patient is still under admission)
<問題一: 是否第一時間插管?>
ANS: 根據目前研究，因Intubation increases intra-thoracic pressure and decreases venous return, threshold for intubation and PPV should be raised in patients with cardiac tamponade
<問題二: Metformin associated lactate acidosis何時要洗腎?>
How to identify MALA?
Patients with MALA had higher lactate (14.7 versus 5.9 mmol/L)
Lactate >8.4 mmol/L, creatinine >2.9 mg/dL, and history of metformin use had a specificity of 99 percent for MALA in patients
Jusomin的泡法及滴法:
133meq NaHCO3 in 1L D5W run 250ml/hr → 33.25 meq/hr
一包CVVH B 250ml, 7% ≈ 200meq → 200meq in 250ml run ? ml/hr = 33.25 ml/hr,
? ≈ 40 ml/hr ≈ 2PC jusomin / hr 若根據uptodate給法 可CVVH每小時run40cc/hr或每小時兩支
H/D indication for acute or chronic severe metformin poisoning:
Severely elevated serum lactate concentration (>20 mmol/L ≈ 181 mg/dL)
Severe metabolic acidosis (pH ≤7.0)
Failure to improve (as determined by pH, lactate concentration, or clinical status) with supportive care and bicarbonate therapy within two to four hours.
<問題三: Cardiac tamponade>
Definition: Chamber compliance ↓↓; Systemic venous return↓↓; Cardiac output↓↓
Etiology: Idiopathic, infectious, Autoimmune, neoplasm, metabolic, drug, Cardiac, trauma, metabolic
Diagnosis: “Clinical diagnosis”, based on PE and history
History and physical examination including
Chest pain, syncope, dyspnea, tachycardia, hypotension, peripheral edema, jugular vein engorgement, pulsus paradoxus
Ultrasound finding
Pericardial effusion, RV diastolic phase collapse, IVC dilatation
Response to pericardiocentesis – 若有則仍高度懷疑cardial tamponade
Acute VS Subacute cardiac tamponade
<問題四: Emergent pericardiocentesis>
Location
Most pericardial fluid in end-diastole
Least amount of interfering structures
找好點之後，上下左右掃一圈，確定進針路徑沒有別的東西
Common approaches:
Subxiphoid/Subcostal:
Steeper angle, longer path,
High risk of injury to cardiac chamber, liver; Less risk of pneumothorax
Can be done during OHCA circumstance
Intercostal, lateral (apical):
Puncture above the rib
Risk of pneumothorax and ventricular puncture
1-2 cm medially to the border of lung margin
Intercostal, medial (parasternal):
Puncture above the rib
Risk of pneumothorax and injury to LIMA (Left internal mamillary artery)
3-5 cm lateral to the sternum to avoid LIMA injury
During puncture:
Head up 30-45⁰(+/- left lateral decubitus)
2-D echocardiogram for guide
Lidocaine for analgesia
Advanced 18 gauze needle cautiously
Aspiration the effusion, advanced 1mm more to fixed in the pericardial space
Seldinger’s technique, inserted dilator and pig-tail
If VPCs or pulsatile blood flow occurs, 退出並祈禱沒事
Contraindication: 幾乎沒有，好處遠大於壞處
Absolute:
Few, often needs operation
Aortic dissection(有爭議)
Relative:
Therapeutic anticoagulation
Thrombocytopenia (PLT<20,000)
Surgical indication:
Acute intrapericardial bleeding due to either acute aortic dissection
Free-wall rupture due to infarction or iatrogenic
Hemopericardium with thrombus
Failure of pericardiocentesis
Traumatic cardiac tamponade
<問題五: Esophago-pericardial fistula (EPF)>
Cause: Chronic esophagitis, foreign body ingestion with perforation, Iatrogenic, Malignancy
Clinical presentation: Chest pain, dyspnea, fever, shock, pneumopericardium, Purulent pericarditis
Diagnosis and Management: Clinical suspicion + CT/esophagogram(CT: pericardium有空氣)
Broad spectrum antibiotics
Pericardial effusion drainage
Non-surgical – esophageal stenting (主流)
Surgical - esophagogastric resection with re-anastomosis
Edited by Andy Mao / Ting-Hao Yang
Reference:
Willner DA, Grossman SA. Pericardiocentesis. [Updated 2022 Mar 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470347/
Chetrit M, Lipes J, Mardigyan V. A Practical Approach to Pericardiocentesis With Periprocedural Use of Ultrasound Training Initiative. Can J Cardiol. 2018;34(9):1229-1232. doi:10.1016/j.cjca.2018.06.004
Ho AM, Graham CA, Ng CS, et al. Timing of tracheal intubation in traumatic cardiac tamponade: a word of caution. Resuscitation. 2009;80(2):272-274. doi:10.1016/j.resuscitation.2008.09.021
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