Pericardiocentesis: Difference between revisions

No edit summary
No edit summary
Line 2: Line 2:
*[[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
***Pericardial effusion
***Diastolic collapse of the right ventricle
***Diastolic collapse of the right atrium (in atrial diastole)
***Diastolic collapse of the right atrium (in atrial diastole)
***Diastolic collapse of the right ventricle
***Plethoric IVC
***Plethoric IVC
***Valvular pulsus parodoxus
***Valvular pulsus parodoxus
Line 31: Line 31:
#NGT if needed to decompress stomach
#NGT if needed to decompress stomach
#Skin prep with iodine or chlorhexidine, followed by sterile drape
#Skin prep with iodine or chlorhexidine, followed by sterile drape
#Consider sedation or local anesthesia but do not delay procedure
#Atropine may be helpful to prevent vasovagal reaction
#Atropine may be helpful to prevent vasovagal reaction
 
==Technique==
==Technique==
===Blind or ECG-Guided===
===Subxiphoid Approach<ref name="NEJM" />===
#Insert needle between xiphoid process and left costal margin at 30-45' angle
#Identify insertion location between xiphoid process and left costal margin
#Aim toward left shoulder
#Insert needle through skin at identified site at 30-45' angle to the skin, aiming toward left shoulder
#Puncture skin
#Remove stylet and attach 3-way stopcock and 20-mL syringe
#Remove obturator of spinal needle
#If utilizing EKG, attach alligator clip from base of needle to any precordial EKG lead
#Attach alligator clip from pericardial needle to any V lead of ECG machine
#If utilizing ultrasound, use real-time subxiphoid view to guide needle toward effusion.
#Slowly advance needle ~6-8cm
#Slowly advance needle while continually aspirating until fluid return
#Stop advancing needle if fluid is aspirated
##If utilizing alligator clip, stop advancing needle if ST elevation noted on monitor - withdraw until ST elevations resolve, reposition needle and continue
#Stop advancing needle and withdraw a few mm if ST elevation seen on ECG
#Aspirate fluid (even a small amount can significantly improve pt status)
#If possible, use properly placed needle to pass a catheter into the pericardial space rather than draining fluid with needle alone
#Disconnect syringe/stopcock and use Seldinger technique to place pericardial drain
#Withdrawl as much fluid as possible
#Obtain post-procedure CXR to rule-out iatrogenic PTX
#CXR to rule-out iatrogenic PTX
 
===Parasternal Approach<ref name="NEJM" />===


===Ultrasound-Guided===
#Use [[Ultrasound: Cardiac|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<ref>Nagdev, A, et al. A novel in-plane technique for ultrasound-guided pericardiocentesis. American Journal of Emergency Medicine. 2013; 31:1424.e5–1424.e9.</ref>===
===Novel In-Plane Technique<ref>Nagdev, A, et al. A novel in-plane technique for ultrasound-guided pericardiocentesis. American Journal of Emergency Medicine. 2013; 31:1424.e5–1424.e9.</ref>===
Line 77: Line 75:
==References==
==References==
<references/>
<references/>


[[Category:Cards]]
[[Category:Cards]]
[[Category:Procedures]]
[[Category:Procedures]]

Revision as of 00:51, 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 ventricle
      • Diastolic collapse of the right atrium (in atrial diastole)
      • 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

  1. Bed to 45˚ angle if pt condition allows (brings heart/pericardium closer to anterior chest wall)
  2. NGT if needed to decompress stomach
  3. Skin prep with iodine or chlorhexidine, followed by sterile drape
  4. Consider sedation or local anesthesia but do not delay procedure
  5. Atropine may be helpful to prevent vasovagal reaction

Technique

Subxiphoid Approach[1]

  1. Identify insertion location between xiphoid process and left costal margin
  2. Insert needle through skin at identified site at 30-45' angle to the skin, aiming toward left shoulder
  3. Remove stylet and attach 3-way stopcock and 20-mL syringe
  4. If utilizing EKG, attach alligator clip from base of needle to any precordial EKG lead
  5. If utilizing ultrasound, use real-time subxiphoid view to guide needle toward effusion.
  6. Slowly advance needle while continually aspirating until fluid return
    1. If utilizing alligator clip, stop advancing needle if ST elevation noted on monitor - withdraw until ST elevations resolve, reposition needle and continue
  7. Aspirate fluid (even a small amount can significantly improve pt status)
  8. Disconnect syringe/stopcock and use Seldinger technique to place pericardial drain
  9. Obtain post-procedure CXR to rule-out iatrogenic PTX

Parasternal Approach[1]

Novel In-Plane Technique[2]

  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 Links

ALIEM Pericardiocentesis

See Also

References

  1. ↑ 1.0 1.1 1.2 Fitch MT, Nicks BA, Pariyadath M, McGinnis HD, Manthey DE. Emergency pericardiocentesis. N Engl J Med. 2012 Mar 22;366(12):e17
  2. ↑ Nagdev, A, et al. A novel in-plane technique for ultrasound-guided pericardiocentesis. American Journal of Emergency Medicine. 2013; 31:1424.e5–1424.e9.
Retrieved from "https://www.wikem.org/w/index.php?title=Pericardiocentesis&oldid=40706"