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Pericardial Effusion

fluid, left, fifth, sac, incision and needle

PERICARDIAL EFFUSION.

The treatment of in ordinary cases is that of the primary disease causing the dropsy. Thus, in Bright's Disease Diaphore tics, Saline Purgatives and, to a lesser extent, Diuretics will be indicated.

Large or simple effusions are the result of inflammatory action in acute rheumatism or in the terminal stage of renal disease. An attempt may he made to cause the absorption of effusion by the admin istration of the diuretics mentioned under Pericarditis.

When the diagnosis of great distension by fluid has been established by the recognised signs aided by the X-ray screen, and the detection of an area of cardiac dulness to the left of the apex-beat and below it, an exploratory puncture should be made with the long needle attached to a large hypodermic syringe. The needle should be inserted through the sterilised skin over this dull area in the fifth or sixth space outside the vertical line of the nipple slightly upwards and to the right in the direction of the apex-beat. Some surgeons advocate puncturing the sac close to the sternum in the fifth space on the left side, or i to 2 inches beyond it in order to avoid wounding the internal mammary artery.

Epigastrir site is in the median line below the apex of the ensiform cartilage whilst the patient is placed in a semi-sitting posture, and the trochar is directed upwards very close to the posterior surface of the ensiform.

The site selected for the preliminary puncture, if fluid has been struck, should be rigidly adhered to for the paracentesis. An aspirator needle or a flat ('urschmann's trochar and canula should be inserted, and the fluid slowly siphoned off till about so oz. are withdrawn. The needle or canula should be held steadily by the fingers whilst the fluid is flowing in order to avoid injury to the ventricular walls.

Pyo-pericardium.—Should the preliminary puncture reveal pus, this may be drawn off by siphonal„;e as in simple effusion, and in the case of children there is a hope that it may not reaccumulate. It is, however,

always better to provide drainage, for which purpose a flap of skin should be turned up exposing the fourth and fifth left costal cartilages. The fifth cartilage should then be carefully excised, opening of the left pleura being avoided, and the internal mammary having been secured the pericardial sac is freely opened, and after the removal of the purulent accumulation a drainage-tube is inserted. Owing to the difficulty of breathing general anmsthesia is usually contra-indicated, and the incisions can be made under cocaine.

Where a left empyema complicates the situation the pericardial sac may sometimes be opened and drained through the incision made for the empyema.

Injuries as stab-wounds of the heart may be also reached and sutured through the above-mentioned incision, but usually it will be found necessary to remove the fourth or sixth costal cartilage in addition to the fifth in order to thoroughly expose the wounded organ, and these operations should when possible be performed under differential pressure in a suitable chamber.

Hcemo-pericardium.—Blood in the pericardium when the result of wounds is best treated by free incision of the sac and ligature of the injured vessels. Blood-stained fluid, the accompaniment of disease of the membrane, may be removed by paracentesis, but the blood effusions occurring in purpuric and scorbutic conditions are best left alone surgically, Chloride of Calcium being administered freely by the mouth.

Pnewno-pericardium.—As this never occurs in the absence of fluid, blood or pus in the cavity, the treatment will consist in aspiration or incision, with provision for free drainage.