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A Cadaveric Model for Pericardiocentesis Training
The Journal of Emergency Medicine, Vol. 44, No. 3, pp. 661–662, 2013 Copyright Ó 2013 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2012.06.019
Techniques and Procedures A CADAVERIC MODEL FOR PERICARDIOCENTESIS TRAINING Pholaphat C. Inboriboon, MD, MPH*1 and Suthaporn Lumlertgul, MD† *Department of Emergency Medicine, University of Rochester, Rochester, New York and †Department of Emergency Medicine, Chulalongkorn University, Bangkok, Thailand Reprint Address: Pholaphat C. Inboriboon, MD, MPH, Department of Emergency Medicine, University of Missouri Kansas City, Truman Medical Center, 2301 Holmes St., Kansas City, MO 64108
, Abstract—Background: Pericardiocentesis is a rare but potentially life-saving procedure. Improper technique can lead to life-threatening complications. Discussion: Described is a cadaveric training model developed to train providers. Conclusion: This cadaveric model allows trainees to familiarize themselves with both proper landmark and ultrasound-based pericardiocentesis technique. Ó 2013 Published by Elsevier Inc.
literature, none of these models are widely utilized. Cost limits the use of mannequin simulation models, whereas other simulation models are limited in their realism of the human body (1,2). Many Emergency Medicine residency programs utilize cadavers for procedural training. Traditionally, pericardiocentesis training in this setting is limited because there is no pericardial effusion. We describe a cadaveric-based pericardiocentesis training model useful for anatomic landmark-based and ultrasound-guided pericardiocentesis training.
, Keywords—cadaver; simulation; pericardiocentesis; training; thoracotomy; model
DISCUSSION Material and Methods
INTRODUCTION
A soft cadaver, large-bore catheter, sutures thoracotomy tray, intravenous setup with saline bag, and methylene blue are needed to create the cadaveric training model. First, the right fifth intercostal space is identified and incised posteriorly towards the scapula and anteriorly towards the right midclavicular line. The rib spreaders are inserted and opened until the right heart border is visualized. This may require expansion of the initial chest wall incision and manipulation of the right lung. The pericardial sac is then identified, and a large-bore catheter, such as a paracentesis catheter, is introduced into the pericardial space using tissue forceps and a number 11 scalpel. The catheter is secured to the pericardial sac via sutures. A prepped saline bag injected with 5 mL of methylene blue is hung to gravity and attached to the catheter via
Pericardiocentesis is a rare but potentially life-saving procedure essential to the practice of Emergency Medicine. Improper technique can lead to life-threatening iatrogenic complications; proper training is essential to minimize risk and maximize patient outcome. Although various simulation training models are described in the
1
Currently, Dr. Inboriboon works at the Department of Emergency Medicine, University of Missouri Kansas City, Truman Medical Center, Kansas City, MO. Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
RECEIVED: 20 December 2011; FINAL SUBMISSION RECEIVED: 9 March 2012; ACCEPTED: 28 June 2012 661
662
P. C. Inboriboon and S. Lumlertgul
Figure 2. Ultrasound-guided pericardiocentesis on the cadaver model. The needle is visualized in the pericardial effusion.
Strengths and Limitations This cadaveric model allows trainees to familiarize themselves with proper landmark-based and ultrasoundguided pericardiocentesis technique. Limitations of this model are 1) the cost and availability of cadavers, 2) the model set-up and installation, 3) the inability to identify needle placement errors that can result in pneumothorax, and 4) inability to simulate cardiac movement during ultrasound-guided pericardiocentesis. CONCLUSION
Figure 1. Fluid aspiration from the pericardiocentesis model. Blue aspirate demonstrates proper cannulation of pericardial space, red aspirate demonstrates iatrogenic cannulation of the heart.
Despite these limitations, this unique teaching innovation can be implemented and utilized in a variety of settings, especially in procedural workshops currently utilizing cadavers. REFERENCES
intravenous tubing. Allow filling of the pericardial sac and assess the surrounding intrathoracic space for extravasation of fluid. If there is no significant extravasation and the pericardial sac is infused with fluid, the model is ready to be used. Perform landmark-based or ultrasound-guided pericardiocentesis. Successful aspiration of fluid from the pericardial sac will result in blue aspirate. Cannulation of the atrium or ventricle will result in red aspirate (Figure 1). Ultrasound can also be used to visualize the location of the needle and verify proper placement (Figure 2).
1. Girzadas D, Zerth H, Harwood R. An inexpensive, easily constructed, reusable task trainer for simulating ultrasound-guided pericardiocentesis. Acad Emerg Med 2009;16:4(Suppl 1):S279. 2. Okuda Y, Quinones J. The use of simulation in the education of emergency care providers for cardiac emergencies. Int J Emerg Med 2008; 1:73–7.
SUPPLEMENTARY DATA Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10. 1016/j.jemermed.2012.06.019.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
http://dx.doi.org/10.1016/j.jemermed.2012.06.019
Techniques and Procedures A CADAVERIC MODEL FOR PERICARDIOCENTESIS TRAINING Pholaphat C. Inboriboon, MD, MPH*1 and Suthaporn Lumlertgul, MD† *Department of Emergency Medicine, University of Rochester, Rochester, New York and †Department of Emergency Medicine, Chulalongkorn University, Bangkok, Thailand Reprint Address: Pholaphat C. Inboriboon, MD, MPH, Department of Emergency Medicine, University of Missouri Kansas City, Truman Medical Center, 2301 Holmes St., Kansas City, MO 64108
, Abstract—Background: Pericardiocentesis is a rare but potentially life-saving procedure. Improper technique can lead to life-threatening complications. Discussion: Described is a cadaveric training model developed to train providers. Conclusion: This cadaveric model allows trainees to familiarize themselves with both proper landmark and ultrasound-based pericardiocentesis technique. Ó 2013 Published by Elsevier Inc.
literature, none of these models are widely utilized. Cost limits the use of mannequin simulation models, whereas other simulation models are limited in their realism of the human body (1,2). Many Emergency Medicine residency programs utilize cadavers for procedural training. Traditionally, pericardiocentesis training in this setting is limited because there is no pericardial effusion. We describe a cadaveric-based pericardiocentesis training model useful for anatomic landmark-based and ultrasound-guided pericardiocentesis training.
, Keywords—cadaver; simulation; pericardiocentesis; training; thoracotomy; model
DISCUSSION Material and Methods
INTRODUCTION
A soft cadaver, large-bore catheter, sutures thoracotomy tray, intravenous setup with saline bag, and methylene blue are needed to create the cadaveric training model. First, the right fifth intercostal space is identified and incised posteriorly towards the scapula and anteriorly towards the right midclavicular line. The rib spreaders are inserted and opened until the right heart border is visualized. This may require expansion of the initial chest wall incision and manipulation of the right lung. The pericardial sac is then identified, and a large-bore catheter, such as a paracentesis catheter, is introduced into the pericardial space using tissue forceps and a number 11 scalpel. The catheter is secured to the pericardial sac via sutures. A prepped saline bag injected with 5 mL of methylene blue is hung to gravity and attached to the catheter via
Pericardiocentesis is a rare but potentially life-saving procedure essential to the practice of Emergency Medicine. Improper technique can lead to life-threatening iatrogenic complications; proper training is essential to minimize risk and maximize patient outcome. Although various simulation training models are described in the
1
Currently, Dr. Inboriboon works at the Department of Emergency Medicine, University of Missouri Kansas City, Truman Medical Center, Kansas City, MO. Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
RECEIVED: 20 December 2011; FINAL SUBMISSION RECEIVED: 9 March 2012; ACCEPTED: 28 June 2012 661
662
P. C. Inboriboon and S. Lumlertgul
Figure 2. Ultrasound-guided pericardiocentesis on the cadaver model. The needle is visualized in the pericardial effusion.
Strengths and Limitations This cadaveric model allows trainees to familiarize themselves with proper landmark-based and ultrasoundguided pericardiocentesis technique. Limitations of this model are 1) the cost and availability of cadavers, 2) the model set-up and installation, 3) the inability to identify needle placement errors that can result in pneumothorax, and 4) inability to simulate cardiac movement during ultrasound-guided pericardiocentesis. CONCLUSION
Figure 1. Fluid aspiration from the pericardiocentesis model. Blue aspirate demonstrates proper cannulation of pericardial space, red aspirate demonstrates iatrogenic cannulation of the heart.
Despite these limitations, this unique teaching innovation can be implemented and utilized in a variety of settings, especially in procedural workshops currently utilizing cadavers. REFERENCES
intravenous tubing. Allow filling of the pericardial sac and assess the surrounding intrathoracic space for extravasation of fluid. If there is no significant extravasation and the pericardial sac is infused with fluid, the model is ready to be used. Perform landmark-based or ultrasound-guided pericardiocentesis. Successful aspiration of fluid from the pericardial sac will result in blue aspirate. Cannulation of the atrium or ventricle will result in red aspirate (Figure 1). Ultrasound can also be used to visualize the location of the needle and verify proper placement (Figure 2).
1. Girzadas D, Zerth H, Harwood R. An inexpensive, easily constructed, reusable task trainer for simulating ultrasound-guided pericardiocentesis. Acad Emerg Med 2009;16:4(Suppl 1):S279. 2. Okuda Y, Quinones J. The use of simulation in the education of emergency care providers for cardiac emergencies. Int J Emerg Med 2008; 1:73–7.
SUPPLEMENTARY DATA Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10. 1016/j.jemermed.2012.06.019.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.