Pericardiocentesis

Indications

• Cardiac tamponade
  • Beck's Triad (JVD, Hypotension, Distant heart sounds) - unlikely to have all 3
  • Ultrasound - RV collapse, plethoric IVC
  • May also see pulsus paradoxus, dyspnea, electrical alternans, low voltage on EKG
• Diagnose cause of pericardial effusion

Contraindications

Emergent procedure - no contraindications in unstable patient

Relative Contraindications:

• For traumatic tamponade, perform ED thoracotomy instead
• Myocardial rupture
• Aortic dissection
• Bleeding diathesis

Equipment

1. Pericardiocentesis kit
   1. Contains equipment to perform seldinger technique (similar to central line)
2. If kit unavailable:
   1. 18ga spinal needle
   2. Syringe
3. Wire w/ alligator clip connected to base of needle and to any V lead of ECG machine
   1. Used to prevent ventricular puncture
4. Ultrasound

Preparation

1. Bed to 45˚ angle (brings heart closer to anterior chest wall)
2. NGT if needed to decompress stomach
3. Subxiphoid/epigastric iodine skin prep
4. Atropine may be helpful to prevent vasovagal reaction

Technique

Blind or ECG-Guided

1. Insert needle between xiphoid process and left costal margin at 30-45' angle
2. Aim toward left shoulder
3. Puncture skin
4. Remove obturator of spinal needle
5. Attach alligator clip from pericardial needle to any V lead of ECG machine
6. Slowly advance needle ~6-8cm
7. Stop advancing needle if fluid is aspirated
8. Stop advancing needle and withdraw a few mm if ST elevation seen on ECG
9. If possible, use properly placed needle to pass a catheter into the pericardial space rather than draining fluid with needle alone
10. Withdrawl as much fluid as possible
11. CXR to rule-out iatrogenic PTX

Ultrasound-Guided

1. Use subxiphoid/parasternal views to choose puncture site (largest area of effusion)
2. Follow same procedure as above except:
   1. Confirm correct placement by injecting agitated saline

Novel In-Plane Technique

1. Skin is prepped
2. Curvilinear probe with sterile cover is placed obliquely over the right chest with indicator to the right shoulder
3. Depth corrected to see only the RV and effusion
4. Needle directed in an in-plane approach at 45°
5. Aspiration is done under direct needle visualization
6. A catheter can be placed under direct visualization using Seldinger technique

Complications

1. Cardiac puncture/hemopericardium
2. Pneumothorax/pneumopericardium
3. Dysrhythmias
   1. PVC (most common)
   2. Vasovagal bradycardia (responsive to atropine)
4. False negative (clotted pericardial blood)
5. False positive (intracardiac puncture)

External Sources

http://www.aliem.com/ultrasound-guided-pericardiocentesis/

Source

• Roberts and Hedges