轉院來的Type A IMH，剛到急診沒多久就Rupture造成Collapse，
雖然立即Echo guided aspiration，針都到位了，就是抽不出血塊，
還好在急診由CVS協助下緊急pericardial window，然後直上OR。
POCUS Indication for this case:
Aortic dissection, type A (Intramural hematoma)
Collapse in ER
for hemopericardium survey
POCUS AIM
Acquisition:
Curvelinear transduce
Subcostal 4 chamber view
Interpretation:
Circumferential & echogenic fluid within pericardial space
Medical decision making:
Echo-guided aspiration (failed due to blood clot)
Prompt bedside surgical pericardial window to evacuate blood clot
Direct to OR for repair
Comments from experts:
ER:打得到抽不出來，真是急診醫師的惡夢
CVS: 由aortic wall 滲出的血水很接近fresh blood，一下就會變成clot而抽不出來，放drain的效果不佳。跟一般的 bloody malignant pericardial effusion不同(雖然是暗紅色，可是不太會有血塊)。
CV:理論上應是prefer surgical drainage just like purulent pericardium
同場加映王瑞芳博士針對這個議題的研究
The effect of different relieving methods on the outcome of out-of-hospital cardiac arrest patients with nontraumatic hemopericardium in the ED.
Abstract
AIMS:
This study aimed to assess the impact of different methods of draining nontraumatic hemopericardium on outcome from patients with out-of-hospital cardiac arrest (OHCA), identify independent predictors of return of spontaneous circulation (ROSC), and examine the ineffective rate of decompression based on subxiphoid pericardiotomy (SP) and percutaneous pericardial catheter drainage (PCD).
METHODS:
Adult patients with OHCA who presented to the ED between May 1, 2000, and October 30, 2006, with moderate to massive nontraumatic hemopericardium were recruited and stratified into 4 groups according to the relieving methods of hemopericardium. Charts were reviewed for various demographic data, resuscitation records, management, and outcome. Patient outcome was recorded as survival to hospital discharge and ROSC, as primary end points. Effective decompression was recorded as a secondary end point. We compared the outcome between the groups.
RESULTS:
A total of 1491 OHCA resuscitation records were prospective collected. There were 23 OHCA patients with moderate to massive nontraumatic hemopericardium. The overall ROSC rate was 39.1% (9/23). There was a clear difference in the ROSC rate between 4 groups (P < .05). The overall rate of survival to hospital discharge was 4.3% (1/23). There was no significant difference in the rate of survival to hospital discharge between the groups. Relieving methods was an independent predictor of ROSC in OHCA patients with nontraumatic hemopericardium (odds ratio, 0.17; 95% confidence interval, 0.4-0.70). There was a significant statistical difference in adequate relief of hemopericardium based on SP and PCD (P < .01).
CONCLUSION:
The early effective decompression method is associated with an increased rate of ROSC for OHCA patients with nontraumatic hemopericardium. Subxiphoid pericardiotomy has a better effective decompression of hemopericardium than PCD.
