pericardiocentsis

[Fish]

Can you provide any literature or studies that support this? (By trauma I assume we are not talking traumatic arrest, but trauma in general)

Or any literature as to why a Paramedic should not be performing this in the field...... A study that has shown it to be detrimental to the patient.

 

[Ecgg]

Prehospital pericardiocentesis is a "look - I'm a better paramedic because I have cool skills in my protocols" intervention.

Similar to RSI. But at least you can make a good argument for RSI.

Here is my argument for pericardiocentesis in the field

Not every pneumothorax needs a field needle decompression but at the point of tension pneumothorax they do.

Same argument can be applied

Not every pericardial effusion needs a field pericardiocentesis but at the point of cardiac tamponade (positive Beck's triad) they do.

Please do inform with your reasoning as to why it should not be done at the point of it being a cardiac tamponade if we have protocols, training and equipment in place along with ultrasound guidance.

 

[DrankTheKoolaid]

Definitely for traumatic cardiac arrest.

 

[medicsb]

Are we supposed to not to perform skills in the field based off of there regularity?

Depends. Crics are probably indicated far more often than pericardiocentesis and is more likely to be successful, as you pointed out. (This is apples vs oranges, really.)

We all know the chance of the procedure is slight, however there are plenty of documented cases of it being effective and working. Still more NOs than YESs. However, it really does come down to this is a last ditch effort to save another human's life prior to pronouncing them dead.

I found only 2 case reports of pericardiocentesis in the prehospital setting - both in Germany, performed early (i.e., not last ditch) by physicians after use of ultrasound (one of them: http://www.ncbi.nlm.nih.gov/pubmed/17716805).

Re-enacting the resuscitation scene from the Abyss is likely to be just as useful as a last ditch effort.

 

[Bullets]

Here is my argument for pericardiocentesis in the field

Not every pneumothorax needs a field needle decompression but at the point of tension pneumothorax they do.

Same argument can be applied

Not every pericardial effusion needs a field pericardiocentesis but at the point of cardiac tamponade (positive Beck's triad) they do.

Please do inform with your reasoning as to why it should not be done at the point of it being a cardiac tamponade if we have protocols, training and equipment in place along with ultrasound guidance.

you can make the same argument with chest seals and we allow BLS to use them with almost no training on the different types of Pneumotoraces or wound anatomy/location.

 

[Fish]

Depends. Crics are probably indicated far more often than pericardiocentesis and is more likely to be successful, as you pointed out. (This is apples vs oranges, really.)



I found only 2 case reports of pericardiocentesis in the prehospital setting - both in Germany, performed early (i.e., not last ditch) by physicians after use of ultrasound (one of them: http://www.ncbi.nlm.nih.gov/pubmed/17716805).

Re-enacting the resuscitation scene from the Abyss is likely to be just as useful as a last ditch effort.

Looking back at my post it appears I poorly worded the "last ditch effort"

I do not mean it to sound as if, Medics are to say to one another hey we are about to call this in lets do the Pericardiocentesis right quick.

You are to perform the skill when you recognize it is indicated....... But due to its low success rate, it is a bit of a Hail Marry.

 

[ExpatMedic0]

its in my CCEMTP book along with escharotomy, for whatever that is worth.

 

[Smash]

What causes acute pericardial tamponade in trauma? If you actually manage to relieve the tamponade, then what? Have you fixed the lacerated/ruptured myocardium or great vessels? Do you just keep going in over and over if PEA continues?
It seems somewhat pointless if you are not fixing the underlying cause. It is not the same as placing an intercostal catheter to allow continuous drainage of air/fluid.

 

[Carlos Danger]

Are we supposed to not to perform skills in the field based off of there regularity?

If that was the case we would not do surgical airways either...
While I know Surgical airways obviously have a higher potential for success and positive outcome, I was strictly using that as a comparision for low use skills.

We all know the chance of the procedure is slight, however there are plenty of documented cases of it being effective and working. Still more NOs than YESs. However, it really does come down to this is a last ditch effort to save another human's life prior to pronouncing them dead.

For the record, I have never performed either of these skills mentioned in the field on a human. Only in training on Dummys and animals.

I'd like to see the facts upon which you base this claim.

 

[Clipper1]

its in my CCEMTP book along with escharotomy, for whatever that is worth.

It was also in Paramedic textbooks several years ago. At one time almost every Paramedic in the US was taught the procedure at least by the textbook and then it was up to their medical director for it being done within their system.

The procedure fell out of favor for several reasons.

1. Very few had the opportunity to perform the skill on a human or even a chance to watch one being done.

2. Few remained competent even in knowledge after school. Just being taught once is not enough.

3. Trauma centers and hospitals were becoming numerous.

4. Helicopter EMS became increasing popular with advanced training for the RNs and EMT-Ps.

5. Too many Paramedics in some of the larger systems to train and maintain competency.

6. Lack of adequate medical oversight to oversee competency or even initial training.

7. Lack of initiative on the providers' part to maintain their own knowledge base and skill level even if through a manikin.

8. The numbers in EMS research were not showing this to an essential skill for the general EMS provider and it took time away from training the skills which could be used everyday.

9. Egos overcoming common sense.
Example:
http://www.benningtonbanner.com/news/ci_21648505/medic-loses-license-over-fatal-crash


When intubation, which some consider to be an essential skill, is questioned because of difficulty to find training sights and inability to maintain competency due to competition for a tube in the field with all the other Paramedics on scene and inadequate oversight to ensure competency why should more skills be introduced? Perfect what you have and prove you are ready to advance.

 

[Summit]

What I want to see is some data demonstrating this as a useful 911 field intervention that has been performed effectively in situations common enough in the emergency environment (not CCT) to warrant it.

I saw some data once that said it was not. Maybe that was a dream... cannot find it.

But, if we have something that might be performed 5 times a year in the US by 911 paramedics, and lets say it improve outcomes 1/5 and worsen them 2/5, it is worse than a waste of time.

Example:
http://www.benningtonbanner.com/news/ci_21648505/medic-loses-license-over-fatal-crash

Wow... just wow... I was thinking "whatever... it's just dramatic reporting" until they listed out the EMS board's charges.

 

[Ecgg]

What causes acute pericardial tamponade in trauma? If you actually manage to relieve the tamponade, then what? Have you fixed the lacerated/ruptured myocardium or great vessels? Do you just keep going in over and over if PEA continues?
It seems somewhat pointless if you are not fixing the underlying cause. It is not the same as placing an intercostal catheter to allow continuous drainage of air/fluid.

Welcome to the world of EMS were most of interventions that we perform do not fix the underlying cause. So with your logic why perform them at all?

Why do 12 lead give ASA, Nitro in an AMI with thrombosed coronary these things are not fixing the underlying cause. If someone got shot in the chest and progresses to the point of tension pneumothorax a form of obstructive shock, why perform needle thoracentesis we are not fixing the underlying cause which is GSW.

Pericardial tamponade is other form of an obstructive shock that compromises ventricular filling producing + JVP, falling Systemic BP, distant heart sounds are indicating it's no longer an effusion that patient can maintain his ventricular filling and BP. So you are correct our introversion will not fix the underlying cause however the patient can supported be with PRBC's, and relieving the fluid in his pericardiac sac which allows a better ventricular filling and will increase CO which is just may help.

If however you can state a strong reason instead of it's not fixing the underlying problem as to why this should not be done in the field by personnel who has had the training, proper equipment along with ultrasound, protocols and medical direction in place for said procedure, I would be glad to hear it.

 

[STXmedic]

Welcome to the word of EMS were most of interventions that we perform do not fix the underlying cause. So with your logic why perform them at all?

 

[Christopher]

Handing the doc the equipment and watching a handful of times is not extensive. And if the RN actually has "extensive" observational experience, I do not see how they'd be that much more appropriate than a medic. But, regardless... very very few would have the procedure indicated and many many fewer would potentially benefit, especially in trauma.

I think EMS would see a bigger gain from finger thoracostomies than pericardiocentesis. Most of the physician based systems perform these in the field with good effect.

 

[Ecgg]

How does "do not fix the underlying cause" = "results are made up and research does not matter"?

 

[ExpatMedic0]

Have you not seen all the clinical trials and research for pre-hospital use of lidocaine? It cures everything from ICP to heart arrhythmias.... wait a second.... or does it

 

[Bullets]

This seems like another skill that falls squarely in the "We can do what doctors do!" field

Medics cant show that they can reliably intubate a patient, and this is still a skill they might use occasionally. yet some want to introduce an even less common perishable skill just because a fraction of a percentage of the population might benefit from the treatment.

In my system, Cardiac Arrest as a result of blunt trauma is generally pronounced at the scene. These are patients that have less than 1% survivability rates, adding this skill isnt going to improve that with any significance

I see medics here on this site chime in on "what should BLS add" threads saying BLS needs to improve at what they are allowed to do now, before we add more whizz-bang stuff. Same thing applies to ALS. Lets see intubation rates increase, Neurologically intact patients post cardiac arrest improve, get everyone on the same page with the care we are providing now before we go sticking needles into a patients heart to save <1%

 

[Christopher]

In my system, Cardiac Arrest as a result of blunt trauma is generally pronounced at the scene. These are patients that have less than 1% survivability rates, adding this skill isnt going to improve that with any significance

The interesting bit is some physician based services have higher rates than <1% for trauma (typically far better w/ penetrating than blunt), but they will do field thoracostomies, clamshell thoracotomies, etc.

 

[VFlutter]

The interesting bit is some physician based services have higher rates than <1% for trauma (typically far better w/ penetrating than blunt), but they will do field thoracostomies, clamshell thoracotomies, etc.

London HEMS is a good example.

 

[Sublime]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660039/

Pericardiocentesis

There is no evidence for prehospital pericardiocentesis. The technique is difficult and associated with cardiac injury. It is unlikely that clotted pericardial blood can be aspirated by a needle, and this technique does not stop continued bleeding from the ventricle into the pericardial sac.