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[1]:
- For traumatic tamponade, perform ED thoracotomy instead
- Myocardial rupture
- Aortic dissection
- Bleeding diathesis
Equipment
- Pericardiocentesis kit
- Contains equipment to perform seldinger technique (similar to central line)
- If kit unavailable:
- 18ga spinal needle
- Syringe
- Wire w/ alligator clip connected to base of needle and to any V lead of ECG machine
- Used to prevent ventricular puncture
- Ultrasound
Preparation
- Bed to 45˚ angle (brings heart closer to anterior chest wall)
- NGT if needed to decompress stomach
- Subxiphoid/epigastric iodine skin prep
- 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)
External Sources
http://www.aliem.com/ultrasound-guided-pericardiocentesis/
Source
- Roberts and Hedges