pericardiocentsis

[VFlutter]

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

This is a quote from the thoracotomy section but I think it is a great point

"This procedure should only be performed by specialist doctors who have the appropriate skills, training and expertise. There is no role for the inexperienced enthusiast to “have a go”."

 

[silver]

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.

You know I would just be very hesitant about proper training in sonography of thoracic region. How frequently would these field providers be practicing this? How versed are they in thoracic anatomy and the potential variations present?

 

[Christopher]

You know I would just be very hesitant about proper training in sonography of thoracic region. How frequently would these field providers be practicing this? How versed are they in thoracic anatomy and the potential variations present?

There are a number of prehospital departments which perform US (Keller TX and Odessa TX, come to mind). US is easy to learn and retain and very useful. A bit cost prohibitive currently, but we're getting closer.

 

[Ecgg]

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

So you are utilizing a consensus paper that states "There is no evidence for prehospital pericardiocentesis." No evidence is not the same as there is evidence for not performing said procedure. Here is direct quite from Advanced Trauma Life Support, 8th Edition, The Evidence for Change



Treatment of cardiactamponade
Pericardiocentesis is described as
the initial management of
traumatic tamponade in the shock
and thoracic chapters
Acute cardiac tamponade due to trauma is best managed by thoracotomy.
Pericardiocentesis may be used as a temporizing maneuver when
thoracotomy is not an available option (LOE 4).70


Kortbeek JB, Al Turki SA, Ali J et al. Advanced Trauma Life
Support 8th edition, the evidence for change. J. Trauma 2008; 64:
1638–50.

These as well

http://cine-med.com/index.php?nav=acs&id=ACS-2745
http://www.ncbi.nlm.nih.gov/pubmed/21143405

 

[silver]

There are a number of prehospital departments which perform US (Keller TX and Odessa TX, come to mind). US is easy to learn and retain and very useful. A bit cost prohibitive currently, but we're getting closer.

Perform diagnostically using like FAST exam model?

 

[Sublime]

So you are utilizing a consensus paper that states "There is no evidence for prehospital pericardiocentesis." No evidence is not the same as there is evidence for not performing said procedure. Here is direct quite from Advanced Trauma Life Support, 8th Edition, The Evidence for Change



Treatment of cardiactamponade
Pericardiocentesis is described as
the initial management of
traumatic tamponade in the shock
and thoracic chapters
Acute cardiac tamponade due to trauma is best managed by thoracotomy.
Pericardiocentesis may be used as a temporizing maneuver when
thoracotomy is not an available option (LOE 4).70


Kortbeek JB, Al Turki SA, Ali J et al. Advanced Trauma Life
Support 8th edition, the evidence for change. J. Trauma 2008; 64:
1638–50.

These as well

http://cine-med.com/index.php?nav=acs&id=ACS-2745
http://www.ncbi.nlm.nih.gov/pubmed/21143405

It's obvious that this is wide spread debate among many specialities. There isnt enough evidence for or against pre-hospital pericardiocentesis, it's just not there. If it is I've yet to see anything conclusive.

I would argue that the procedure is not appropriate for the majority of EMS systems out there.

I believe it may have a place in some select systems where they can provide a proper training and retengency program. It's just unrealistic for most places though.

 

[Christopher]

Perform diagnostically using like FAST exam model?

Yes, and for cardiac exams, vascular access, and I believe a clinical trial on stroke recognition (doppler visualization of the MCA ).

 

[Ecgg]

It's obvious that this is wide spread debate among many specialities. There isnt enough evidence for or against pre-hospital pericardiocentesis, it's just not there. If it is I've yet to see anything conclusive.

I would argue that the procedure is not appropriate for the majority of EMS systems out there.

I believe it may have a place in some select systems where they can provide a proper training and retengency program. It's just unrealistic for most places though.

I agree with this statement. That is why some programs have it in place and many more do not.

 

[Carlos Danger]

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.

That is not how it works. The intervention has to prove it's worth, not the other way around.

Using your logic, we could implement a protocol that calls for synchronized cardioversion as therapy for refractory seizures. Cuz hey, after all, I doubt there are any studies that show it's detrimental....

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.

For sure, a therapy need not "fix the underlying cause" to be useful.

However, comparing EKG/ASA/Nitro with pericardiocentesis is comparing apples and oranges.

One has research and strong consensus backing it up, the other does not.

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.

The "strong reason" is that 1) It hasn't been shown to improve outcomes, 2) It is a technically difficult procedure, 3) It is extremely rarely indicated, and 4) There is no good way to train for it.

I would not say that "no paramedic anywhere should ever do a pericardiocentesis for any reason", but I think that there are many things which are much more useful and much more important that our time and money should go to rather than a skill that, for most paramedics, might be performed a couple times in a career and has very, very little chance of improving outcomes.

FWIW, I have actually done a good handful of these in the field. Not enough to be an expert by any means, but I have some idea what I am talking about when it comes to this procedure.

 

[Rialaigh]

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.

IMO...this has as much to do with efficient use of resources as it does whether it works or not.

IF, and this would be one helluva unbelievable huge IF, every pericardiocentsis performed last year was 100% successful with a 100% survival and neuro intact at discharge rate, I would still not advocate putting this in our EMS system now.

We could spend a fraction of that amount of money on diabetes education and have paramedics educate diabetics on correct and proper diabetes management through working out, eating correctly, and proper medication administration and blood sugar recording, we could save more lives, improve the quality of life on more lives, and reduce millions of dollars in unneeded ER visits, admissions, and surgeries.....


I can think of a hundred better things to spend money on then field pericardiocentsis. Even if the survival rate for these things (neuro intact) was 10 times what it is now..

 

[CANDawg]

I know pericardiocentesis is in the scope for Paramedics here in Alberta, but I don't think its in the protocols for the primary EMS provider, which means it would likely be something that you would want to consult with medical control about. I agree it is a bit of a Hail Mary, but if you're ready to give it a shot, its because nothing else has worked.

I don't necessarily agree with the "medics shouldn't do it because they don't have experience doing it" argument either. If they are properly trained in the first place and continue to keep their skills up to date, that should be sufficient in an emergent situation. The RN argument is a tad bullocks as well - seeing is not doing. I could watch hours of youtube videos on how to perform an appendectomy, but it doesn't mean that I should go do one over someone else who has been trained. The key, again, is proper continuing education that goes beyond just reading a textbook and taking a test.

If you start cutting everything out of a medic scope that they rarely use on the basis "they don't have the experience"..... you would have an EMT.

 

[Rialaigh]

I know pericardiocentesis is in the scope for Paramedics here in Alberta, but I don't think its in the protocols for the primary EMS provider, which means it would likely be something that you would want to consult with medical control about. I agree it is a bit of a Hail Mary, but if you're ready to give it a shot, its because nothing else has worked. I don't necessarily agree with the "medics shouldn't do it because they don't have experience doing it" argument either. If they are properly trained in the first place and continue to keep their skills up to date, that should be sufficient in an emergent situation.

If you start cutting everything out of a medic scope that they rarely use on the basis "they don't have the experience"..... you would have an EMT.

You would have a medic that performs procedures that are appropriate and that he is well trained and versed with. Which is what we want...

I don't want to be a medic that can do a lot of stuff, but people look at me and say "he almost never does that". I want to be a medic that can do appropriate effective interventions at an expert level enough times to be considered seasoned at it...

 

[chaz90]

You would have a medic that performs procedures that are appropriate and that he is well trained and versed with. Which is what we want...

I don't want to be a medic that can do a lot of stuff, but people look at me and say "he almost never does that". I want to be a medic that can do appropriate effective interventions at an expert level enough times to be considered seasoned at it...

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. If we only kept interventions that I did often enough to be considered an expert, I could start IVs, give Zofran, and run a 12 lead. I'm competent enough and comfortable using any of my equipment or administering any of my drugs when indicated, but there's plenty of stuff I carry that I may never use. The key is training enough to keep skills up and having a good enough reason to keep that skill available to paramedics.

Also, this isn't necessarily in reference to pericardiocentesis.

 

[CANDawg]

You would have a medic that performs procedures that are appropriate and that he is well trained and versed with. Which is what we want...

I don't want to be a medic that can do a lot of stuff, but people look at me and say "he almost never does that". I want to be a medic that can do appropriate effective interventions at an expert level enough times to be considered seasoned at it...

The problem is that in a normal medical field you can make that a reality. You have specialists that focus on a few types of procedures, so the volumes allow them to remain proficient. You need heart surgery? You go to a cardiologist. You need respiratory support? You see a respiratory technician.

The problem in EMS is that specialization is impossible. Even if you could narrow each call down to the exact resources it required, trying to maintain different staff experts in different things and getting them to the patient when the patient needs them would be an exercise in futility. That's the reason you pick and choose what could be lifesaving, conducted in the types of environments EMS operates in, trained to relative proficiency in a reasonable amount of time, and performed using resources available to EMS. If something matches those criteria, then it should be considered for EMS use.

The answer isn't narrowing scopes, it is expanding training and continuing education. I'm fully in support of Paramedic being a degree program. Where I live the average paramedic course is two years long, and I think that's a tad short. A solid, in-depth and quality education combined with regular (consider even daily!) quality continuing education is enough to combat the fact that a practitioner may not use every skill in his/her scope during a shift.

We want to expand EMS, to make it a bigger and more valuable part of the medical system. Trimming scopes under the auspices that a medic would never be able to be proficient at a certain skill is not the way to do that.

Rant over.

 

[Fish]

I remember the last time I was apart of a thread like this, an RSI thread. The disagreements went on forever. So, I am going to turn in early on this one. Agree to disagree. I do enjoy reading the post though, nice to get everyone's perspective.

 

[NomadicMedic]

It's true. It's like arguing about religion. . Nobody wins.

 

[Ecgg]

One of the days I will come to morbidity and mortality conference at a community hospital and tell the doc after disclosure of a case where routine intervention resulted in mortality "Perfect what you have and prove you are ready to advance!" you idiot.

We should most certainly eliminate all these advanced procedures RSI, intubations, ventilator management, needle thoracentesis from all these damn doc's who spent the last 15 years in family practice clinic and the last time they saw the vent it was the iron lung during their residency. Now decided to move and find themselves in charge in the ER at a rural hospital. BLS before doctoring god damn it guys! Because everyone knows the way you solve the issue of education and training is by taking away interventions.

 

[Akulahawk]

It's true. It's like arguing about religion. . Nobody wins.

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!

 

[Rialaigh]

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. If we only kept interventions that I did often enough to be considered an expert, I could start IVs, give Zofran, and run a 12 lead. I'm competent enough and comfortable using any of my equipment or administering any of my drugs when indicated, but there's plenty of stuff I carry that I may never use. The key is training enough to keep skills up and having a good enough reason to keep that skill available to paramedics.

Also, this isn't necessarily in reference to pericardiocentesis.

I think uncommon is a relative term. Every medic is likely to pace or cardiovert someone every year (running 9-1-1) some do it on a near weekly basis. I would be hard pressed to say that 1 in 1,000 medics will perform a pericardiocentsis this year.

 

[Rialaigh]

The problem is that in a normal medical field you can make that a reality. You have specialists that focus on a few types of procedures, so the volumes allow them to remain proficient. You need heart surgery? You go to a cardiologist. You need respiratory support? You see a respiratory technician.

The problem in EMS is that specialization is impossible. Even if you could narrow each call down to the exact resources it required, trying to maintain different staff experts in different things and getting them to the patient when the patient needs them would be an exercise in futility. That's the reason you pick and choose what could be lifesaving, conducted in the types of environments EMS operates in, trained to relative proficiency in a reasonable amount of time, and performed using resources available to EMS. If something matches those criteria, then it should be considered for EMS use.

The answer isn't narrowing scopes, it is expanding training and continuing education. I'm fully in support of Paramedic being a degree program. Where I live the average paramedic course is two years long, and I think that's a tad short. A solid, in-depth and quality education combined with regular (consider even daily!) quality continuing education is enough to combat the fact that a practitioner may not use every skill in his/her scope during a shift.

We want to expand EMS, to make it a bigger and more valuable part of the medical system. Trimming scopes under the auspices that a medic would never be able to be proficient at a certain skill is not the way to do that.

Rant over.

The thing is, any given medic in this current ems system (US specifically) is not proficient at certain skills. Education has to come before expanded scope. You can't have an expanded scope and then have a "oh :censored::censored::censored::censored:" moment and decide you need more education.


We in EMS have the general mind set that any improved survival rates are better...


if you think that improving survival rates in a tiny obscure portion of the population at the expense of much additional training and costs in resources in EMS is better than I hate to tell you but you are wrong...


I would pose the simple question for this topic of pericardiocentsis, what do you think the opportunity cost would be of training all US paramedics to be even slightly comfortable or proficient in this skill...(in other words what could be accomplished in EMS or the healthcare system with the same amount of training hours and dollars). I assure you there are better ways to spend our time and money then improving trauma arrest survival rates through this skill