pericardiocentsis

[Smash]

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.

The difference is that doing a 12 lead can identify pathology early which leads to earlier intervention and improved outcomes for the patient. Giving aspirin leads to improved patient outcomes. Nitrates, well I'm with you on that, there is precious little evidence for it's use, although when used carefully there is probably less likelihood of harm.
The difference with placing an intercostal catheter to relieve a tension pneumothorax in the field is that after placement it remains in place, it can be done with relative ease, will be done more frequently and has less potential to lead to harm and is therefore a reasonable temporising measure until a formal chest tube can be placed.

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.

I'm aware of the patho of a pericardial effusion. However, in the setting of trauma (haemopericardium) as opposed to a pericardial effusion, even if you manage to evacuate blood/clot, what are you going to do in the field, to stop the pericardium from refilling?
I would be very surprised if you have PRBCs, and even if you do, putting more red in is not going to stop the red from getting out around the heart. Bear in mind that tamponade typically comes from penetrating trauma. How are you going to help that laceration to the ventricle/atrium/great vessels in the field?

If you are lucky it may have been from a small tear and a resultant slow bleed and it may buy you some time (if it actually works). However it buys that time at the risk of iatrogenic injury to (depending on the method) the liver, lungs, internal mammaries, great vessels and heart. That's a pretty poor risk/benefit equation in my eyes.

The ATLS material quoted is... well, it's ATLS. However even they admit that there is poor/no evidence for the use of the needle. Where it is (sort of) supported it is in the context of a temporising measure until thoracotomy is performed. If that wait is minutes in the ER that may be ok, but in the field it ceases to be even a temporising measure.
As for the other references, I'm not even sure what Cine Med is. Is it a journal? Do they employ a spellchecker? Regardless they report a single case study of dubious provenance. The other reference is again a single case study of a paediatric patient in an ICU. Hardly the same as a paramedic poking around in a patient's chest in the field.

 

[Carlos Danger]

But there is absolutely reason to have uncommonly performed procedures kept in the ALS scope. Do I cardiovert or pace someone often? No, not even close, but these are absolutely skills we need to maintain in our scope.

And again, those are skills that clearly affect outcomes, and are technically easy to perform, and easy to simulate and practice.

Not so with pericardiocentesis....

 

[chaz90]

I agree there is a huge difference in expected benefit for those procedures vs. pericardiocentesis. My point there was just in response to the previous comment that we should only do skills we perform often enough to be considered an "expert."

 

[Clipper1]

Since this procedure was taught to all US Paramedics at one time and was in most protocols for US EMS agencies, why not ask the old timers who have been around for more than 20 years what happened? Nothing new here at all. Most will probably tell you they never saw a need to perform the procedure in the field nor heard of anyone doing it. A few will tell you about the over enthusiastic Paramedics who performed it whenever they got a trauma code or just about anyone with PEA because "dead is dead" and you can't make it worse than that.

The problem with a trauma code involving blood in the pericardial sac is that you can pull all the blood out you want but that will not repair the damage and the blood will return. This is emphasized in ATLS which is why surgeons get a good laugh at arguments like this.

Things change in medicine. Some are also trying to get away from futile medicine such as working trauma codes since you probably can not fix what caused the code in the field. Probably some here might like to go back to epi straight to the heart which was also taught.

Believe it or not but many nurses have been around long enough to see what happens before, during and after procedures. Caring for the patient during that time is a little more than just watching a YouTube video as someone related it do. It is also a little more than just one procedure.

 

[Clipper1]

Actually, that's where you're wrong. The spectators win because they get to see a vicious fight to the death and the popcorn dealers make out like bandits!

I find this post very disrespectful to all the soldiers who have lost their lives fighting wars which are fought with religion as an issue. There is nothing cool about watching people die fighting to the death.

 

[Summit]

I agree there is a huge difference in expected benefit for those procedures vs. pericardiocentesis. My point there was just in response to the previous comment that we should only do skills we perform often enough to be considered an "expert."

There is a huge difference between competency in these two skills. The psychomotor skills required for pericardiocentesis are much greater than slapping on some pads. The consequences of performing the skill incorrectly make pericardiocentesis a procedure with a much higher likelihood of patient harm vs a lower likelihood of patient improvement. Combine that problem with a procedure that is so rarely indicated that in an entire career, most medics won't even know a medic who had a patient where it was indicated... well as other posters have said, it is an opportunity cost at best, and a direct danger to patients at worst.

 

[Akulahawk]

I find this post very disrespectful to all the soldiers who have lost their lives fighting wars which are fought with religion as an issue. There is nothing cool about watching people die fighting to the death.

Have you forgotten the Roman Gladiators? You have two guys who were made to fight, each convinced that they were going to win and that they had their deity of choice on their side. Who won? Neither of those guys. The spectators did as they got their entertainment (bloody, vicious, potentially repulsive as it was, it was Rome after all...) and the people that sold snacks and refreshments made out as well because they had a captive audience, most of whom would be thirty and/or hungry.

Personally, I'd rather not actually see people fight to the death. The other thing is that many millions (if not more) of lives have been lost over whose religion is right. Is it right? No. Is this kind of conflict happening currently? Yes. Still doesn't make it right. Some of the most vicious fighting has been because people fervently believe that their deity of choice is on their side and they're killing in their name. Still doesn't make it right. From a Roman's point of view, it makes for great entertainment.

Now pass the popcorn!