Pericardiocentesis

Pericardiocentesis is the removal of pericardial fluid using needle aspiration to relieve cardiac tamponade in the hemodynamically compromised patient. Click here to view a video produced by Ultrasound Podcast on how to perform pericardiocentesis.

Indications in the Emergency Department

Note – emergency pericardiocentesis is NOT indicated in the patient with a pericardial effusion who is clinically stable with normal vital signs.

  • To manage pericardial tamponade.

Clinical signs of pericardial tamponade

  • Becks triad – hypotension, jugular venous distension, muffled heart sounds.
  • Pulses paradoxus >10mmHg.
  • Severe respiratory distress.
  • PEA cardiac arrest.
  • ECG – electrical alternans, low voltage QRS.
  • POCUS - ECHO findings – RV diastolic collapse, LV collapse IVC dilatation with loss of respiratory variations, swinging of the heart in the pericardial fluid.
  • In patients with clinical suspicion of tamponade – low cardiac output symptoms, hypotension, tachycardia, pulses paradoxus – the presence of a moderate to large effusion on ECHO confirms tamponade.

Relative Contraindications

There are no absolute contraindications if it is an immediately life saving procedure. In addition, timely availability of a more suitably qualified practitioner (i.e. a patient who is not moribund) would also be a relative contraindication.

  • Traumatic pericardial effusion with instability – this is an indication for an emergency thoracotomy.
  • Myocardial rupture.
  • Aortic dissection.
  • Severe bleeding disorder.

Equipment required

  • Resuscitation trolley.
  • The patient should have – 2 x IV access, Cardiac monitoring, O2 applied.
  • ECG machine.
  • If available - Wire with alligator clips – to attach between needle and ECG machine.
  • Sterile gloves.
  • Skin cleanser.
  • Bedside USS.
  • 18G spinal needle or large bore needle from central line kit.
  • Three way tap.
  • 20mL syringe.

Method

Ultrasound guided pericardiocentesis is the recommended safe method for pericardiocentesis – it allows for real time visualisation of the procedure and reduces the risk of injury. There are three currently described techniques:

  • Subxiphoid approach which has been around for a long time and has previously been used "blind", prior to ready availability of bedside US but currently done with US guidance, it is probably the safest technique if you have to do it blind
  • Apical approach under US guidance which carries an increased risk of pneumothorax
  • Parasternal approach, which is US guided and now described in terms of 2 sub types , the lateral to medial approach and the more recently described medial to lateral approach.

EM Curious Blog summarising some techniques

Subxiphoid approach;

  1. Identify the junction between the left costal margin and the xiphoid process.
  2. Prep the skin and use local anaesthetics as clinically appropriate.
  3. If available and if time permits – attach crocodile clip from base of needle to the V1 lead of an ECG machine.
  4. Place the Cervi-linear US probe in the subxiphoid area, angle it up towards the chest using the liver as a window.
  5. Insert the needle parallel to the probe and direct it at 45 degrees, towards the L shoulder.
  6. Aspirate as you advance the needle until you aspirate fluid -stop advancing the needle.
  7. If your needle is connected to the ECG V1 lead monitor for any ST segment elevation on the monitor during needle advancement. If this occurs it suggests you have made epicardial contact with the needle – withdraw the needle until the ST segments normalise.

Apical approach

This approach is can result in pneumothorax due to the lingula of the left lung.

  1. Prep the skin and use local anaesthetics as clinically appropriate.
  2. Place the Phased Array ultrasound probe on the chest wall and identify the apex, enter the skin at 1 cm lateral to this aiming for the R shoulder.
  3. Try to insert the needle at the location where the probe is closest to the black anechoic stripe of fluid.
  4. If available and if time permits – attach crocodile clip from base of needle to the V1 lead of an ECG machine.
  5. Insert the needle over the superior aspect of the rib so as to avoid damaging the neurovascular bundle.
  6. If your needle is connected to the ECG V1 lead monitor for any ST segment elevation on the monitor during needle advancement. If this occurs it suggests you have made epicardial contact with the needle – withdraw the needle until the ST segments normalise.
  7. Aspirate as you advance the needle until you aspirate fluid – stop advancing the needle.

Parasternal approach

This approach is often preferred due to its proximity to the pericardial fluid and to a reduced risk of damage to liver or lung.

  1. Prep the skin and use local anaesthetics as clinically appropriate.
  2. Place the Cervilinear ultrasound probe on the chest wall in a left parasternal position at approximately the 4th intercostal space, to obtain a parasternal long axis view of the heart.
  3. Try to insert the needle at the location where the probe is closest to the black anechoic stripe of fluid.
  4. If available and if time permits – attach crocodile clip from base of needle to the V1 lead of an ECG machine.
  5. Insert the needle over the superior aspect of the rib so as to avoid damaging the neurovascular bundle.
  6. If your needle is connected to the ECG V1 lead monitor for any ST segment elevation on the monitor during needle advancement. If this occurs it suggests you have made epicardial contact with the needle – withdraw the needle until the ST segments normalise.
  7. Aspirate as you advance the needle until you aspirate fluid – stop advancing the needle.

Lateral to Medial Approach from ALIEM

Paper on Medial to Lateral Approach

If placing a pericardial drain – use seldinger technique through needle to introduce drain.

** Removal of 5-10mL of fluid can increase the stroke volume by as much as 25-50% and result in a dramatic increase in cardiac output and blood pressure evidenced by an improvement in the patient’s vital signs.**

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