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  • Volume I:
    First Thirty Minutes
    • Section 1
      Acute Care Algorithm/ Treatment Plans/ Acronyms
      • CALS Approach
        • CALS Universal Approach
        • Patient Transport
      • Airway
        • Rapid Sequence Intubation Algorithm/Rescue Airways
        • Endotracheal Intubation FlowSheet
        • Rapid Sequence Intubation Medications
        • Rapid Sequence Intubation Drug Calculator
        • Rapid Sequence Intubation Dosage Chart
        • Obstructed Airway Algorithm Adult and Pediatric
        • Initial Laboratory Studies
      • Cardiovascular
        • CPR Steps for Adults, Children, and Infants
        • Automated External Defibrillator Algorithm
        • Ventricular Fibrillation-Pulseless Ventricular Tachycardia Algorithm
        • Pulseless Electrical Activity Algorithm-Adult and Peds
        • Asystole Algorithm-Adult and Peds
        • Bradycardia Algorithm
        • Tachycardia Algorithm
        • Atrial Fibrillation/Atrial Flutter Algorithm
        • Electrical Cardioversion Algorithm-Adult and Pediatric
        • Chest Pain Evaluation Algorithm
      • Emergency Preparedness
        • Therapeutic Hypothermia
        • Mobilization Checklist
        • Symptom Recognition-Therapy
        • Blast Injuries
      • Fluids & Electrolytes
        • Causes of Anion and Non-Anion Gap Acidosis
      • Infection
        • Sepsis Guidelines
      • Neonatal
        • Neonatal Resuscitation Algorithm
        • Inverted Triangle-APGAR Score
        • Drugs in Neonatal Resuscitation Algorithm
      • Neurology
        • Altered Level of Consciousness
        • Glasgow Coma Scale-Adult, Peds,Infant
        • Tips From the Vowels Acronym
        • NIH Stroke Scale (Abbreviated)
        • Status Epilepticus Treatment Plan
      • Obstetrics
        • Postpartum Hemorrhage Algorithm
        • Shoulder Dystocia—HELPERR
        • Vacuum Delivery Acronym-ABCDEFGHIJ
      • Ophthalmology
        • Central Retinal Artery Occlusion
        • Chemical Burn Exposure to Eye
      • Pediatrics
        • Pediatric Equipment Sizes
        • Modified Lund Browder Chart
      • Trauma
        • Shock Acronym-Shrimpcan
        • Burn Management Treatment Plan
        • Initial Care of Major Trauma
        • Trauma Flow Sheet
    • Section 2
      Universal Approach
      • CALS Universal Approach To Emergency Advanced Life Support
    • Section 3
      Steps 1-6
      • Steps 1-6
      • Step 1: Activate the Team
      • Step 2: Immediate Control and Immobilization
      • Step 3: Initial Survey
      • Step 3: Simultaneous Team Action By Team Members
      • Step 4: Preliminary Clinical Impression
      • Step 5: Working Diagnosis and Disposition
      • Step 6: Team Process and Review
    • Section 4
      Preliminary Impression/Focused Clinical Pathways
      • Pathway 1: Altered Level of Consciousness (Adult and Pediatric)
      • Pathway 2: Cardiovascular Emergencies (Adult and Pediatric)
      • Pathway 3: Gastrointestinal/Abdominal Emergencies (Adult and Pediatric)
      • Pathway 4: Neonatal Emergencies
      • Pathway 5: Obstetrical Emergencies
      • Pathway 6: Adult Respiratory
      • Pathway 7: Pediatric Respiratory
      • Pathway 8: Adult Trauma (Secondary Survey for Adults)
      • Pathway 9: Pediatric Trauma (Secondary Survey for Trauma in Children)
  • Volume II:
    Resuscitation Procedures
    • Section 5
      Airway Skills
      • Airway Skills 1: Aids to Intubation
      • Airway Skills 2: Bag-Valve-Mask Use
      • Airway Skills 3: Orotracheal Intubation
      • Airway Skills 4: Rapid Sequence Intubation
      • Airway Skills 5: Cricoid Pressure and the BURP Technique
      • Airway Skills 6: Esophageal Tracheal Combitube
      • Airway Skills 7: King Airway
      • Airway Skills 8: Intubating Laryngeal Mask Airway
      • Airway Skills 9: Nasotracheal Intubation
      • Airway Skills 10: Topical Anesthesia
      • Airway Skills 11: Retrograde Intubation
      • Airway Skills 12: Tracheal Foreign Body Removal
      • Airway Skills 13: Cricothyrotomy
      • Airway Skills 14: Tracheotomy
      • Airway Skills 15: Tracheotomy in Infants
      • Airway Skills 16: Transtracheal Needle Ventilation
    • Section 6
      Breathing Skills
      • Section 6 Breathing Skills Portals
      • Breathing Skills 1: Chest Tube Insertion
      • Breathing Skills 2: Chest Suction and Autotransfusion
      • Breathing Skills 3: Endobronchial Tube
      • Breathing Skills 4: Heliox
      • Breathing Skills 5: Needle Thoracostomy
    • Section 7
      Circulation Skills
      • Section 7 Circulation Skills Portals
      • Circulation Skills 1: Arterial and Venous Catheter Insertion
      • Circulation Skills 2: Central Venous Access
      • Circulation Skills 3: Central Venous Pressure Measurement
      • Circulation Skills 4: Emergency Thoracotomy
      • Circulation Skills 5: Intraosseous Needle Placement (Adult)
      • Circulation Skills 6: Pericardiocentesis
      • Circulation Skills 7: Rewarming Techniques
      • Circulation Skills 8: Saphenous Vein Cutdown
      • Circulation Skills 9: Transvenous Cardiac Pacing
    • Section 8
      Disability Skills
      • Section 8 Disability Skills Portals
      • Disability Skills 1: Skull Trephination
      • Disability Skills 2: Raney Scalp Clips
    • Section 9
      Trauma Skills
      • Trauma Skills Portals
      • Trauma Skills 1: Compartment Pressure Measurement
      • Trauma Skills 2: Femur Fracture Splinting
      • Trauma Skills 3: Pelvic Fracture Stabilization
      • Trauma Skills 4: Suprapubic Cystostomy
    • Section 10
      X-Rays Skills
      • X-ray Skills 1: Cervical Spine Rules and Use of Imaging Portal
      • X-ray Skills 2: Cervical Spine X-ray Interpretation
      • Xray Skills 3: Interpretation of a Pelvic X-ray
  • Volume III:
    Definitive Care
    • Section 11
      Airway
      • Rapid Sequence Intubation Portal
      • Airway Obstruction Portal
      • Heliox Treatment Portal
      • Ventilator Management Portal
      • Noninvasive Ventilatory Support Portal
      • Inspiratory Impedance Threshold Device Portal
      • Status Asthmaticus Portal
      • Anaphylaxis Portal
    • Section 12
      Cardiovascular
      • Cardiovascular 1: Classification of Pharmacological (Therapeutic) Interventions Portal
      • Cardiovascular 2: Cardiac Rhythms Portal
      • Cardiovascular 3: Pharmacology of Cardiovascular Agents Portal
      • Cardiovascular 4: Endotracheal Drug Delivery
      • Cardiovascular 5: Ventricular Fibrillation/Pulseless Ventricular Tachycardia Portal
      • Cardiovascular 6: Pulseless Electrical Activity Portal
      • Cardiovascular 7: Asystole Treatment Portal
      • Cardiovascular 8: Tachycardia Treatment Portal
      • Cardiovascular 9: Electrical Cardioversion Portal
      • Cardiovascular 10: Bradycardia Treatment Portal
      • Cardiovascular 11: Acute Coronary Syndromes Portal (Acure Ischemic Chest Pain)
      • Cardiovascular 12: Acute Heart Failure Portal
      • Cardiovascular 13: Hypertensive Crises Portal
      • Cardiovascular 14: Digitalis Toxicity Portal
      • Cardiovascular 15: Long QT Syndrome Portal
      • Cardiovascular Diagnostic Treatment Portals
    • Section 13
      Emergency Preparedness
      • Emergency Preparedness 1: Community-Wide Collaboration Portal
      • Emergency Preparedness 2: Approaches to Planning
      • Emergency Preparedness 3: Hazard Vulnerability Analysis Portal
      • Emergency Preparedness 4: Incident Command System Portal
      • Emergency Preparedness 5: Emergency Management Program Portal
      • Emergency Preparedness 6: Basic All Hazards Response Portal
      • Emergency Preparedness 7: Rapid and Efficient Mobilization Portal
      • Emergency Preparedness 8: Emergency Event Response Classifications Portal
      • Emergency Preparedness 9: Triage Portal
      • Emergency Preparedness 10: Surge Capacity Planning and Scarce Resources Guidelines
      • Emergency Preparedness 11: Glossary of Terms
      • Emergency Preparedness 12: Resources
      • Emergency Preparedness 13: Introduction to Nuclear, Biological, and Chemical Warfare
      • Emergency Preparedness 14: Nuclear Devices Portal
      • Emergency Preparedness 15: Acute Radiation Syndrome Portal
      • Emergency Preparedness 16: Biological Agents Portal
      • Emergency Preparedness 17: Chemical Agents Portal
      • Emergency Preparedness 18: Explosion and Blast Injuries Portal
      • Emergency Preparedness 19: Patient Isolation Precautions
      • Emergency Preparedness 20: Additional References and Resources
    • Section 14
      Endocrine and Metabolic
      • Endocrine and Metabolic 1: Adrenal Crisis Portal
      • Endocrine and Metabolic 2: Diabetic Ketoacidosis Portal
      • Endocrine and Metabolic 3: Myxedma Coma (Severe Hypothyroidism) Portal
      • Endocrine and Metabolic 4: Thyroid Storm Portal (Severe Thyrotoxicosis/Hyperthyroidism)
      • Endocrine and Metabolic 5: Hyperosmolar (Hyperglycemic) Non-Ketotic State Portal
      • Endocrine and Metabolic 6: Acid-Base Portal Concepts and Clinical Considerations
      • Endocrine and Metabolic 7: Disorders of Electrolyte Concentration Portal
    • Section 15
      Environmental
      • Environmental 1: Hypothermia Portal
      • Environmental 2: Hyperthermia/Heat Stroke Portal
      • Environmental 3: Burns Management Portal
      • Environmental 4: Near Drowning Portal
      • Environmental 5: High Altitude Illness Portal
      • Environmental 6: Snake Bite Portal
    • Section 16
      Farming
      • Farming 1: Respiratory Illnesses Portal
      • Farming 2: Farm Wounds/Amputation Portal
      • Farming 3: Chemical Exposures Portal
    • Section 17
      Gastrointestinal/
      Abdominal
      • Gastrointestinal/Abdominal 1: Esophageal Varices Portal
    • Section 18
      Geriatrics
      • Geriatrics 1: General Aging Portal
    • Section 19
      Infection
      • Infection 1: Adult Pneumonia
      • Infection 2: Meningitis Portal
      • Infection 3: Sepsis in Adults Portal
      • Infection 4: Abdominal Sepsis Portal
      • Infection 5: Tetanus Immunization Status Portal
    • Section 20
      Neonatal
      • Neonatal 1: Neonatal Resuscitation Algorithm
      • Neonatal 2: Drugs in Neonatal Resuscitation
      • Neonatal 3: Meconium Suctioning Portal
      • Neonatal 4: Umbilical Artery and Vein Cannulation Portal
      • Neonatal 5: Inverted Triangle/Apgar Score Portal
      • Neonatal 6: Meningitis/Sepsis in Newborn Portal
      • Neonatal 7: Respiratory Distress Syndrome Scoring System Portal
    • Section 21
      Neurology
      • Neurology 1: Status Epilepticus Portal
      • Neurology 2: Stroke Portal
      • Neurology 3: NIH Stroke Scale Portal
      • Neurology 4: Phenytoin and Fosphenytoin Loading Portal
      • Neurology 5: Increased Intracranial Pressure Portal
    • Section 22
      Obstetrics
      • Obstetrics 1: Physiology of Pregnancy Portal
      • Obstetrics 2: Ultrasound Use Portal
      • Obstetrics 3: Bleeding in Early Pregnancy/Miscarriage Portal
      • Obstetrics 4: Dilatation and Curettage Portal
      • Obstetrics 5: Fetal Heart Tone Monitoring Portal
      • Obstetrics 6: Preterm Labor Management Portal
      • Obstetrics 7: Bleeding in the Second Half of Pregnancy Portal
      • Obstetrics 8: Hypertension In Pregnancy Portal
      • Obstetrics 9: Trauma in Pregnancy Portal
      • Obstetrics 10: Emergency Cesarean Section Portal
      • Obstetrics 11: Imminent Delivery Portal
      • Obstetrics 12: Malpresentations and Malpositions: Breech, Occiput Posterior Portal
      • Obstetrics 13: Assisted Delivery Portal
      • Obstetrics 14: Shoulder Dystocia Portal
      • Obstetrics 15: Third-stage and Postpartum Emergencies Portal
      • Obstetrics 16: Thromboembolic Disease and Pregnancy Portal
    • Section 23
      Pediatrics
      • Pediatrics 1: Physiologic and Anatomic Considerations Portal
      • Pediatrics 2: Tracheal Foreign Body Portal
      • Pediatrics 3: Epiglottitis Portal
      • Pediatrics 4: Laryngotracheal Bronchitis (Croup) Portal
      • Pediatrics 5: Bacterial Tracheitis Portal
      • Pediatrics 6: Bronchiolitis Portal
      • Pediatrics 7: Pneumonia Portal
      • Pediatrics 8: Sepsis Portal
      • Pediatrics 9: Meningitis Portal
      • Pediatrics 10: Diphtheria Portal
      • Pediatrics 11: Glasgow Coma Scale Portal
      • Pediatrics 12: Intraosseous Vascular Access
    • Section 24
      Sedation/
      Pain Control/
      Anesthesia
      • Sedation/Pain Control/Anesthesia 1: Procedural Sedation
      • Sedation/Pain Control/Anesthesia 2: Management of Combative, Agitated, Delirious Patients
      • Sedation/Pain Control/Anesthesia 3: Malignant Hyperthermia Portal
    • Section 25
      Toxicology
      • Toxicology 1: Systematic Approach
      • Toxicology 2: Essential Antidotes Portal
      • Toxicology 3: Acetaminophen Overdose Portal
      • Toxicology 4: Aspirin Overdose Portal
      • Toxicology 5: Tricyclic Antidepressants Overdose Portal
      • Toxicology 6: Beta Blocker Toxicity Portal
      • Toxicology 7: Calcium Channel Blocker Toxicity Portal
      • Toxicology 8: Bendodiazepine Overdose Portal
      • Toxicology 9: Alcohol Withdrawal Portal
      • Toxicology 10: Toxic Alcohols: Methanol and Ethylene Glycol
      • Toxicology 11: Cocaine Ingestion Portal
      • Toxicology 12: Narcotic Overdose Portal
      • Toxicology 13: Amphetamine Analog Intoxication Portal
      • Toxicology 14: Iron Ingestion Portal
      • Toxicology 15: Carbon Monoxide Poisoning Portal
      • Toxicology 16: Hyperbaric Oxygen and Normobaric Oxygen
      • Toxicology 17: Cyanide Poisoning Portal
      • Toxicology 18: Organophosphates Toxicity Portal
    • Section 26
      Trauma Care
      • Trauma Care 1: Shock Portal
      • Trauma Care 2: Shock Evaluation Overview Portal
      • Trauma Care 3: Use of Hemostatic Agents to Control Major Bleeding Portal
      • Trauma Care 4: Severe Traumatic Brain Injury—Adult 
      • Trauma Care 5: Severe Traumatic Brain Injury—Pediatric
      • Trauma Care 6: Compartment Syndrome
    • Section 27
      Tropical Medicine
      • Tropical Medicine 2: Introduction
      • Tropical Medicine 3: Fever and Systemic Manifestations
      • Tropical Medicine 4: Gastrointestinal and Abdominal Manifestations
      • Tropical Medicine 5: Dermatological Manifestations
      • Tropical Medicine 6: Muscular Manifestations (Including Myocardium)
      • Tropical Medicine 7: Neurological Manifestations
      • Tropical Medicine 8: Ocular Manifestations
      • Tropical Medicine 9: Pulmonary Manifestations
      • Tropical Medicine 10: Urogenital Manifestations
      • Tropical Medicine 11: Disorders of Nutrition and Hydration
      • Tropical Medicine 12: Medicine in Austere Environs
      • Tropical Medicine 13: Antiparasitic Primer
      • Tropical Medicine 14: Concise Parasitic Identification
      • Tropical Medicine 15: Bibliography
    • Section 28
      Ultrasound
      • Ultrasound 1: Emergency Ultrasound Applications Portal
      • Ultrasound 2: Emergency Ultrasound Techniques Portal

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Circulation Skills 6:

Pericardiocentesis

Penetrating trauma to the chest should alert the team to the possible presence or development of cardiac tamponade. Beck's triad (muffled heart sounds, distended neck veins, and hypotension) is usually present if the patient is not also hypovolemic. It is not always present. Ultrasound makes the diagnosis quick and easy.

7_cs_6_A


7_cs_6_B

A Seldinger technique pericardiocentesis set (Wood set by Cook Critical Care Co.)

Any patient in shock should undergo ultrasound by the emergency care team. If a pericardial effusion is seen and cardiac tamponade seems to be the correct diagnosis, do the following:

  1. Insert the exploring needle from a percutaneous pericardiocentesis set next to the xiphoid process under the left costal margin directed toward the patient’s left shoulder. Attach a 35 mL syringe to the needle.

  2. When blood returns through the exploring needle, extract a few mL and reapply the ultrasound probe. Inject the blood back into the chest rapidly. The turbulence produced will be seen on ultrasound "lighting up" the pericardial fluid and not appearing in the ventricles, positively identifying the position of the needle.

  3. If the needle is in the pericardial sac, remove 35 mL of blood. This will restore stroke volume to near normal, and the patient will improve.

  4. Insert the guidewire of the set into the pericardial sac through the needle. Before removing the needle, make a stab incision with the #11 blade on the needle through the fascial layers of the abdomen

  5. Pass the dilator of the set over the wire into the pericardial sac. Remove the dilator and pass the pigtail catheter of the set over the wire into the pericardial sac. Remove the wire. Attach a stopcock and syringe for repeated aspirations of blood.

Obviously, this procedure takes time. Removing 35 mL immediately buys the time necessary to get this done.

When an ultrasound machine is not available, the emergency physician should use pericardiocentesis to establish the diagnosis of cardiac tamponade. The classic Beck’s Triad, unfortunately, is not always present. A significant mechanism of injury (penetrating chest wound or blunt chest trauma), probability of a myocardial infarction about 3 or 4 days previously, an illness suggestive of pericarditiis, a probable aortic dissection, and bigeminy on ECG are other clues. A chest x-ray may reveal a globular appearance of the cardiac shadow. If the needle touches the myocardium, PVCs will result, and you may feel the heart beating against the needle.

Pericardiocentesis is a temporizing measure. Repeated aspirations may be necessary before definitive surgery can take place. If the pericardiocentesis attempt fails to return blood, the blood has most likely clotted. If the patient is in mortal distress with loss of consciousness, a thoracotomy would be needed, allowing the performance of an internal pericardiocentesis. See Vol II—Circ Skills 4 Emergency Thoracotomy.

References

  1. Spodick DH. The technique of pericardiocentesis. J Crit Illness. 1987;2(7):91-96.

  2. Plummer D, Brunette D, Asinger R, Ruiz E. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med. 1992;21(6):709-712.

Edition 13-October 2011

Copyright©CALS. Comprehensive Advanced Life Support | © 2012 CALS Program