II. Indications
III. Contraindications: Emergency Pericardiocentesis
- Pericardial Effusion with stable Vital Signs and no sign of Cardiac Tamponade
IV. Precautions
- Do not delay Pericardiocentesis in Cardiac Tamponade
- Dyspnea, Tachycardia, Hypotension progress rapidly to Cardiac Arrest
- Hypoperfusion is an indication for Pericardiocentesis
-
Traumatic Pericardial Effusion (Penetrating Trauma)
- Pericardiocentesis may temporize but does not supplant Emergency Thoracotomy
- Emergency Thoracotomy is the treatment of choice for Penetrating Trauma with application pressure on heart wound
- Pericardiocentesis for Penetrating Trauma is unlikely to relieve tamponade (as bleeding will continue until wound is repaired)
V. Imaging: Ultrasound
- Transducer: 2.5-3.5 MHz with indicator pointed to patient's right side
- Guide Pericardiocentesis needle (see below)
- Confirm Cardiac Tamponade
- See Pericardial Effusion
- Right atrium collapses in systole
- Right ventricle collapses in diastole
- Vena cava dilated without respiratory variation in size
VI. Preparation
- Identify Ultrasound window with best approach for given patient
- Identify window with greatest pocket of fluid (sub-xiphoid, apical or parasternal)
- Sub-Xiphoid window has been historically taught as a landmark approach (non-Ultrasound guided)
- However needle distance from skin to Pericardium is longest from sub-xiphoid approach
- Safest Ultrasound-guided window is often the apical window (Pericardium is closest to skin at apex)
- Identify window with pocket of fluid with only pericardial pocket and not heart in-line with needle approach
- Parasternal approach has been advocated as having the least intervening structures between skin and Pericardium
- Apply sterile probe cover (if no delays)
- Prep region with antiseptic (e.g. Hibiclens) and drape
-
Local Anesthetic with Lidocaine 1% (conscious patient, if no delays)
- Eliminate any bubbles from the syringe as these will interfere with Ultrasound visualization
- Consider saline in syringe to inject into pericardial sac to visualize small bubbles floating in fluid (confirms position)
- Consider raising head of bed to 30 degrees to better localize effusion (non-arrest, relatively stable patients only)
- Prepare needle and syringe
- Needle 16-18 gauge, 6 inch (15 cm) with catheter (micropuncture kit or Pericardiocentesis kit)
- Syringe 20-35 cc with 3 way stop-cock attached
-
General technique pointers
- Observe while threading guidewire into pericardial sac to confirm not in ventricle
VII. Technique: Apical Approach (preferred Ultrasound approach)
- See Preparation above
- Position Ultrasound to apical view
- Needle is inserted adjacent to Ultrasound probe
- Insert needle at Ultrasound probe oriented toward cardiac apex (towards the right Shoulder)
- Aspirate while inserting needle
- Watch the needle enter the largest pocket of fluid and aspirate Pericardial Effusion
VIII. Technique: Sub-Xiphoid Approach
- See Preparation above
- Position Ultrasound in sub-xiphoid position
- EKG monitoring may be used if Ultrasound is not available
- Needle is inserted adjacent to Ultrasound probe
- Angle the needle at 45 degrees, and directed towards the left Shoulder
- Aspirate while inserting needle
- Watch the needle enter the largest pocket of fluid
- Aspirate Pericardial Effusion
IX. Technique: Parasternal Approach (PLAX View)
- Precaution
- Left anterior descending artery may be lacerated when approaching Pericardium from this view
- Position Ultrasound lateral to needle entry site
- Insert needle perpendicular to chest (90 degrees)
- Fifth intercostal space
- Immediately lateral to Sternum
- Aspirate while inserting needle
- Watch the needle enter the largest pocket of fluid
- Aspirate Pericardial Effusion
X. Technique: EKG Monitoring (if Ultrasound not available)
- Sudden ST Elevation on EKG (current of injury) suggests needle contact with Myocardium
- Withdraw needle slightly if ST Elevation occurs
- ST Elevation that persists should prompt complete needle removal
XI. Technique: Post-aspiration
- Consider replacing needle with 14-gauge flexible catheter using seldinger technique
- Follow-up Chest XRay following Pericardiocentesis to evaluate for complications
- Consult thoracic surgery for definitive care
XII. Resources
- Pericardiocentesis Video (NEJM)
XIII. References
- (2008) ATLS, p. 109
- Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete's Beach
- Orman, Dawson and Mallin in Herbert (2013) EM:Rap 13(1): 4-6
- Swaminathan and Weingart in Herbert (2021) EM:Rap 21(5): 12-3