Pericardiocentesis

Indications

1. Relieve cardiac tamponade
   1. Definitive treatment in non-hemorrhagic tamponade
   2. Temporizing measure in hemorrhagic tamponade while awaiting thoracotomy
2. Diagnose cause of pericardial effusion

Contraindications

1. Unstable: none

Equipment

1. Pericardiocentesis kit
   1. Contains equipment to perform seldinger technique (similar to central line)
2. If kit unavailable:
   1. 18ga spinal needle
   2. Syringe
3. Wire w/ alligator clip connected to base of needle and to any V lead of ECG machine
   1. Used to prevent ventricular puncture
4. Ultrasound

Preparation

1. Bed to 45˚ angle (brings heart closer to anterior chest wall)
2. NGT if needed to decompress stomach
3. Subxiphoid/epigastric iodine skin prep
4. Atropine may be helpful to prevent vasovagal reaction

Technique

Blind or ECG-Guided

1. Insert needle between xiphoid process and left costal margin at 30-45' angle
2. Aim toward left shoulder
3. Puncture skin
4. Remove obturator of spinal needle
5. Attach alligator clip from pericardial needle to any V lead of ECG machine
6. Slowly advance needle ~6-8cm
7. Stop advancing needle if fluid is aspirated
8. Stop advancing needle and withdraw a few mm if ST elevation seen on ECG
9. If possible, use properly placed needle to pass a catheter into the pericardial space rather than draining fluid with needle alone
10. Withdrawl as much fluid as possible
11. CXR to rule-out iatrogenic PTX

Ultrasound-Guided

1. Use subxiphoid/parasternal views to choose puncture site (largest area of effusion)
2. Follow same procedure as above except:
   1. Confirm correct placement by injecting agitated saline

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)

Source

• Roberts and Hedges