Procedure

Emergency Pericardiocentesis

search

Emergency Pericardiocentesis, Pericardiocentesis, Ultrasound Guided Pericardiocentesis

  • See Also
  1. Echocardiogram
  • Indications
  1. Cardiac Tamponade
  • Contraindications
  • Emergency Pericardiocentesis
  1. Pericardial Effusion with stable Vital Signs and no sign of Cardiac Tamponade
  • 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)
  1. Transducer: 2.5-3.5 MHz 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
  • Preparation
  1. Identify Ultrasound window with best approach for given patient
    1. Identify window with greatest pocket of fluid (sub-xiphoid, apical or parasternal)
    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. 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
    4. Parasternal approach has been advocated as having the least intervening structures between skin and Pericardium
  2. Apply sterile probe cover (if no delays)
  3. Prep region with antiseptic (e.g. Hibiclens) and drape
  4. 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)
  5. Consider raising head of bed to 30 degrees to better localize effusion (non-arrest, relatively stable patients only)
  6. 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
  7. General technique pointers
    1. Observe while threading guidewire into pericardial sac to confirm not in ventricle
  • 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
  • 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
  1. Precaution
    1. Left anterior descending artery may be lacerated when approaching Pericardium from this view
  2. Position Ultrasound lateral to needle entry site
  3. Insert needle perpendicular to chest (90 degrees)
    1. Fifth intercostal space
    2. Immediately lateral to Sternum
  4. Aspirate while inserting needle
  5. Watch the needle enter the largest pocket of fluid
    1. Aspirate Pericardial Effusion
  • 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
  • Technique
  • Post-aspiration
  1. Consider replacing needle with 14-gauge flexible catheter using seldinger technique
  2. Follow-up Chest XRay following Pericardiocentesis to evaluate for complications
  3. Consult thoracic surgery for definitive care
  • Resources
  1. Pericardiocentesis Video (NEJM)
    1. http://www.youtube.com/watch?v=BQTVqUPimdk
  • References
  1. (2008) ATLS, p. 109
  2. Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete's Beach
  3. Orman, Dawson and Mallin in Herbert (2013) EM:Rap 13(1): 4-6
  4. Swaminathan and Weingart in Herbert (2021) EM:Rap 21(5): 12-3