Emergency Pericardiocentesis

Indications

• Symptoms of cardiac tamponade such as Beck’s triad¹:
  • Jugular venous distention
  • Distant heart sounds
  • Hypotension
• Other signs
  • Pulsus paradoxus greater than 10 mmHg
  • Low voltage QRS
  • Electrical alternans
  • Enlarged cardiac silhouette
• Dyspnoea and tachycardia are the most common symptoms experienced
• Symptom burden is dependent on the acuity of pericardial effusion build up
• Risk factors
  • Metastatic cancer
  • History of mediastinal radiation
  • End-stage renal disease
  • Tuberculosis
  • Traumatic injury
  • Recent cardiac surgery

Contraindication

• Relative
  • A relative contraindication exists for traumatic pericardial effusion with unstable vital signs as this is an indication for an emergency thoracotomy; there will be rapid re-accumulation of blood within the pericardium
  • Myocardial rupture
  • Aortic dissection
  • Severe bleeding disorder
• Nil absolute contraindications

Complications

• Cardiac dysrhythmias
• Cardiac puncture
• Pneumothorax
• Coronary vessel injury
• Peritoneal puncture
• Liver or stomach injury
• Puncture of the internal thoracic artery
• Diaphragmatic injury

Equipment

• Code cart and resuscitation equipment
• Haemodynamic monitoring
• Echocardiogram/ultrasound
• ECG monitoring
• 18-gauge spinal needle
• Three-way tap
• 20 mL syringe
• Anti-bacterial skin cleanser
• Wire with alligator clips
• Sterile gloves and gown
• Local anaesthetic if permissable

Method

1. Palpate surface landmarks for the xiphoid process
2. Clean area with anti-bacterial skin cleanser
3. Drape the area
4. Use local anaesthetic if time permits

Sub-Xiphoid Approach

1. Consider raising the head by 30-45 degrees
2. Insert the spinal needle with the stylet in place using the subxiphoid approach and an ultrasound as guidance
3. Remove the stylet once entered the skin/dermal tissue and connect the three way stop clock and a 2 mL syringe
4. Advance the needle towards the left shoulder while aspirating continuously
5. Withdraw fluid from the pericardial effusion
6. Once happy, attach tubing to a three-way stop clock to allow further removal

Parasternal Approach

1. Similarly insert the needle but use a perpendicular approach at the 5th intercostal space just lateral to the sternum using an ultrasound to find the largest area of collection
2. Remove the stylet on entering the skin
3. Attach three way needle and 20 mL syringe

Electrocardiographic Monitoring

• Connect the spinal needle to a precordial lead using the aligator clips
  
• Monitor for ST elevation in associated lead while advancing the needle which indicates advancement of the needle too far
• Withdraw the needle until ST-elevation resolves and re-direct the needle for pericardiocentesis

Aftercare

• Obtain ultrasound and chest X-ray to assess for complications such as pleural effusion and pneumothorax
• Ongoing monitoring

Sources

• Fitch, M.T., McGinnis, H.D., 2012. Emergency Pericardiocentesis. n engl j med.

Footnotes

1. Note that all signs rarely appear together and when they do indicate a patient is peri-arrest ↩