Pericardiocentesis: Difference between revisions
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==Indications== | ==Indications== | ||
*Cardiac tamponade | *[[Cardiac tamponade]] | ||
**Beck's Triad (JVD, Hypotension, Distant heart sounds) - unlikely to have all 3 | **Beck's Triad (JVD, Hypotension, Distant heart sounds) - unlikely to have all 3 | ||
**Ultrasound | **Ultrasound | ||
***Pericardial effusion | |||
***Diastolic collapse of the right atrium (in atrial diastole) | |||
***Diastolic collapse of the right ventricle | |||
***Plethoric IVC | |||
***Valvular pulsus parodoxus | |||
**May also see pulsus paradoxus, dyspnea, electrical alternans, low voltage on EKG | **May also see pulsus paradoxus, dyspnea, electrical alternans, low voltage on EKG | ||
*Diagnose cause of pericardial effusion | *Diagnose cause of pericardial effusion |
Revision as of 00:45, 18 June 2015
Indications
- Cardiac tamponade
- Beck's Triad (JVD, Hypotension, Distant heart sounds) - unlikely to have all 3
- Ultrasound
- Pericardial effusion
- Diastolic collapse of the right atrium (in atrial diastole)
- Diastolic collapse of the right ventricle
- Plethoric IVC
- Valvular pulsus parodoxus
- May also see pulsus paradoxus, dyspnea, electrical alternans, low voltage on EKG
- Diagnose cause of pericardial effusion
Contraindications
Emergent procedure - no absolute contraindications in unstable patient
Relative Contraindications[1]:
- For traumatic tamponade, perform ED thoracotomy instead
- Myocardial rupture
- Aortic dissection
- Bleeding diathesis
Equipment
- Pericardiocentesis kit (contains equipment to perform drain placement via Seldinger technique)
- If kit unavailable: 18ga spinal needle, 20mL syringe
- Can also use abdominal paracentesis kit
- Ultrasound if available; or,
- Wire w/ alligator clip connected to base of needle and to any precordial lead of ECG machine
Preparation
- Bed to 45˚ angle if pt condition allows (brings heart/pericardium closer to anterior chest wall)
- NGT if needed to decompress stomach
- Skin prep with iodine or chlorhexidine, followed by sterile drape
- Atropine may be helpful to prevent vasovagal reaction
Technique
Blind or ECG-Guided
- Insert needle between xiphoid process and left costal margin at 30-45' angle
- Aim toward left shoulder
- Puncture skin
- Remove obturator of spinal needle
- Attach alligator clip from pericardial needle to any V lead of ECG machine
- Slowly advance needle ~6-8cm
- Stop advancing needle if fluid is aspirated
- Stop advancing needle and withdraw a few mm if ST elevation seen on ECG
- If possible, use properly placed needle to pass a catheter into the pericardial space rather than draining fluid with needle alone
- Withdrawl as much fluid as possible
- CXR to rule-out iatrogenic PTX
Ultrasound-Guided
- Use subxiphoid/parasternal views to choose puncture site (largest area of effusion)
- Follow same procedure as above except:
- Confirm correct placement by injecting agitated saline
Novel In-Plane Technique[2]
- Skin is prepped
- Curvilinear probe with sterile cover is placed obliquely over the right chest with indicator to the right shoulder
- Depth corrected to see only the RV and effusion
- Needle directed in an in-plane approach at 45°
- Aspiration is done under direct needle visualization
- A catheter can be placed under direct visualization using Seldinger technique
Complications
- Cardiac puncture/hemopericardium
- Pneumothorax/pneumopericardium
- Dysrhythmias
- PVC (most common)
- Vasovagal bradycardia (responsive to atropine)
- False negative (clotted pericardial blood)
- False positive (intracardiac puncture)