Emergency Pericardiocentesis

Aka: Emergency Pericardiocentesis, Pericardiocentesis, Ultrasound Guided Pericardiocentesis

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II. Indications

  1. Emergency Pericardiocentesis
    1. Cardiac Tamponade
  2. Non-emergent evaluation (by experienced operator)
    1. Evaluation of undiagnosed or large Pericardial Effusions

III. Contraindications

  1. Absolute Contraindications
    1. Aortic Dissection
    2. Ventricular rupture following Myocardial Infarction
    3. Iatrogenic or Traumatic hemopericardium
  2. Relative Contraindications (non-emergent, non-tamponade presentations)
    1. Pericardial Effusion with stable Vital Signs and no sign of Cardiac Tamponade
      1. Do not perform Emergency Pericardiocentesis (defer to experienced operator, e.g. cath lab interventionist)
    2. Coagulopathy
      1. INR >1.5
      2. Platelet Count <50,000
      3. Anticoagulation
    3. Loculated Pericardial Effusion
    4. Severe Pericardial Effusion

IV. Precautions

  1. Do not delay Pericardiocentesis in Cardiac Tamponade
    1. Dyspnea, Tachycardia, Hypotension progress rapidly to Cardiac Arrest
    2. Hypoperfusion is an indication for Pericardiocentesis
  2. Traumatic Pericardial Effusion (Penetrating Trauma)
    1. Pericardiocentesis may temporize but does not supplant Emergency Thoracotomy
    2. Emergency Thoracotomy is the treatment of choice for Penetrating Trauma with application pressure on heart wound
    3. Pericardiocentesis for Penetrating Trauma is unlikely to relieve tamponade (as bleeding will continue until wound is repaired)

V. Imaging: Ultrasound

  1. Transducer: 2.5-3.5 MHz cardiac phased array probe with indicator pointed to patient's right side
  2. Guide Pericardiocentesis needle (see below)
  3. Confirm Cardiac Tamponade
    1. See Pericardial Effusion
    2. Right atrium collapses in systole
    3. Right ventricle collapses in diastole
    4. Vena cava dilated without respiratory variation in size

VI. Preparation

  1. Identify Ultrasound window with best approach for given patient
    1. Identify window with greatest pocket of fluid (sub-xiphoid, apical or parasternal)
      1. Optimal site is largest fluid pocket for the shortest skin to effusion distance
    2. Sub-Xiphoid window has been historically taught as a landmark approach (non-Ultrasound guided)
      1. However needle distance from skin to Pericardium is longest from sub-xiphoid approach
    3. Parasternal approach may be preferred if adequate pericardial fluid volume
      1. Least intervening structures between skin and Pericardium
      2. Avoid the internal mammary artery (internal thoracic artery) by staying 2 cm lateral to the Sternum
    4. Safest Ultrasound-guided window is often the apical window (Pericardium is closest to skin at apex)
      1. Identify window with pocket of fluid with only pericardial pocket and not heart in-line with needle approach
  2. Apply sterile probe cover (if no delays)
  3. Prep region with antiseptic (e.g. Chlorhexidine) and sterile drape
  4. Sterile technique with mask and cap, sterile gown and gloves
  5. Local Anesthetic with Lidocaine 1% (conscious patient, if no delays)
    1. Eliminate any bubbles from the syringe as these will interfere with Ultrasound visualization
    2. Consider saline in syringe to inject into pericardial sac to visualize small bubbles floating in fluid (confirms position)
  6. Patient in supine position
    1. Consider raising head of bed to 30 degrees to better localize effusion (non-arrest, relatively stable patients only)
  7. Prepare needle and syringe
    1. Needle 16-18 gauge, 6 inch (15 cm) with catheter (micropuncture kit or Pericardiocentesis kit)
    2. Syringe 20-35 cc with 3 way stop-cock attached
  8. In Emergency Pericardiocentesis, needle aspiration alone may be used to stabilize Cardiac Tamponade
    1. However, ideally seldinger guidewire is placed through needle
    2. Pericardial Effusion recurrence rates approach 50% for needle Pericardiocentesis alone (12% with catheter)
      1. Rafique (2011) Am J Cardiol 108(12):1820-5 +PMID: 21907951 [PubMed]
  9. Catheter placement
    1. Observe while threading guidewire into pericardial sac to confirm not in ventricle
    2. Remove needle
    3. Make small incision at guidewire entry in skin
    4. Use dilator into soft tissue
    5. Catheter threaded over the wire and then remove wire
    6. Aspirate fluid with 60 ml syringe
      1. Aspirate fluid until no further drainage
    7. Catheter may be attached to a sterile drainage bag placed below heart level
      1. Allowed to drain to gravity
  10. Ultrasound During and After procedure
    1. Demonstrate decreasing Pericardial Effusion with aspiration (not ventricular aspiration)
    2. Demonstrate resolution of Cardiac Tamponade

VII. Technique: Parasternal Approach (PLAX View)

  1. Precautions
    1. Left anterior descending artery (LAD) may be lacerated when approaching Pericardium from this view
    2. Avoid the internal mammary artery (internal thoracic artery) by staying 2 cm lateral to the Sternum
  2. Pre-Ultrasound with cardiac phased array probe to visualize in PLAX View
    1. Identify fluid pockets
  3. Position Linear Ultrasound probe (with sterile cover) lateral to needle entry site
    1. Use in-plane technique, visualizing needle along its entire course
  4. Insert needle at 45 degree angle to chest, directed laterally
    1. Left 4th intercostal space
    2. Lateral to Sternum by 2 cm to avoid internal mammary artery (internal thoracic artery)
  5. Aspirate while inserting needle
  6. Watch the needle enter the largest pocket of fluid
    1. Aspirate Pericardial Effusion

VIII. Technique: Apical Approach (preferred Ultrasound approach)

  1. See Preparation above
  2. Position Ultrasound to apical view
  3. Needle is inserted adjacent to Ultrasound probe
    1. Insert needle at Ultrasound probe oriented toward cardiac apex (towards the right Shoulder)
    2. Aspirate while inserting needle
    3. Watch the needle enter the largest pocket of fluid and aspirate Pericardial Effusion

IX. Technique: Sub-Xiphoid Approach

  1. See Preparation above
  2. Position Ultrasound in sub-xiphoid position
    1. EKG monitoring may be used if Ultrasound is not available
  3. Needle is inserted adjacent to Ultrasound probe
    1. Angle the needle at 45 degrees, and directed towards the left Shoulder
    2. Aspirate while inserting needle
    3. Watch the needle enter the largest pocket of fluid
      1. Aspirate Pericardial Effusion

X. Technique: EKG Monitoring (if Ultrasound not available)

  1. Sudden ST Elevation on EKG (current of injury) suggests needle contact with Myocardium
  2. Withdraw needle slightly if ST Elevation occurs
  3. ST Elevation that persists should prompt complete needle removal

XI. Technique: Post-aspiration

  1. Consider replacing needle with 14-gauge flexible catheter using seldinger technique if not already performed (see above)
  2. Follow-up Chest XRay following Pericardiocentesis to evaluate for complications (Pneumothorax, Pneumomediastinum)
  3. Consult thoracic surgery or intervention cardiology for definitive care
  4. Vital Signs
    1. Every 15 minutes for the first hour after procedure
    2. Then every 30 min in the second hour after procedure
    3. Then resume standard monitoring
  5. Monitoring while pericardial drain is in place
    1. Complete Blood Count daily
    2. Telemetry monitoring
    3. Flush drain with 5 ml sterile saline every 8 hours
  6. Drain discontinuation
    1. May discontinue pericardial drain once output <50 ml/day (and bedside echo without reaccumulation of fluid)
    2. Patient performs Valsalva Maneuver during drain removal
    3. Apply pressure dressing to area of catheter for 48 hours
  7. Medications
    1. Antibiotic prophylaxis of Pericardiocentesis is NOT neeeded
    2. Consider Colchicine 0.6 mg orally twice daily for 4 weeks (non-malignant Pleural Effusions)
      1. Reduces risk of Pericardial Effusion recurrence

XII. Labs

  1. Blood testing
    1. See Pericardial Effusion
    2. Complete Blood Count with differential
    3. Comprehensive metabolic panel
    4. Troponin
    5. Thyroid Stimulating Hormone
    6. Consider rheumatologic testing (ANA, RF, Anti-Topoisomerase I Antibody, Anticentromere Antibody)
    7. Consider Quantiferon-TB
  2. Pericardial Fluid typical studies
    1. Cell count with differential
    2. Glucose
    3. Fluid culture and Gram Stain
    4. Cytology
  3. Other pericardial fluid tests as directed by presentation
    1. Tuberculosis (AFB culture, AFB RNA PCR, Adenosine deaminase)
    2. Fungal Cultures
  4. References
    1. Esherick (2025) Pericardiocentesis, Hospital Procedures Course

XIII. Complications

  1. Major (2.5 to 3.5%)
    1. Arrhythmias (including Bradycardia)
    2. Pneumopericardium
    3. Pneumothorax
    4. Hemothorax
    5. Infection
  2. Minor (<1.5%)
    1. Myocardial perforation
    2. Vascular injury
      1. Coronary ArteryLaceration (esp. parasternal or apical approach)
      2. Internal mammary artery injury (parasternal approach)
    3. Abdominal organ injury (subxiphoid approach)
      1. Liver, bowel, Stomach, diaphragm injury
  3. References
    1. Esherick (2025) Pericardiocentesis, Hospital Procedures Course

XIV. Resources

  1. Pericardiocentesis Video (NEJM)
    1. http://www.youtube.com/watch?v=BQTVqUPimdk

XV. References

  1. (2008) ATLS, p. 109
  2. Esherick (2025) Pericardiocentesis, Hospital Procedures Course
  3. Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete's Beach
  4. Orman, Dawson and Mallin in Herbert (2013) EM:Rap 13(1): 4-6
  5. Swaminathan and Weingart in Herbert (2021) EM:Rap 21(5): 12-3

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