Ref: Pulmonary Resident Essentials. (2014, December 6). Emergency Pericardiocentesis NEJM [Video]. YouTube. https://www.youtube.com/watch?v=GcoAHYcngEw

Overview

Pericardiocentesis is a life-saving procedure used to drain fluid from the pericardial sac in the setting of pericardial tamponade. It can be performed emergently in the ED or ICU using either landmark or ultrasound guidance.

Indications

• Pericardial tamponade (traumatic or medical)
• Large pericardial effusion causing hemodynamic compromise
• Diagnostic aspiration in suspected pericarditis or malignancy

Contraindications

• Relative: Small/chronic effusion, severe bleeding disorder, myocardial rupture, aortic dissection, traumatic tamponade (proceed to thoracotomy)
• Absolute: None, if patient is unstable in tamponade or arrested

Equipment

• Sterile gloves and gown
• Chlorhexidine and sterile drapes
• Local anesthetic (e.g., lignocaine 1%)
•  Pericardiocentesis needle or 16–18G needle (extra long cannula)
• 20–50mL syringe
• Extension tubing
• 3-way tap
• ECG monitoring (optional ECG connection to needle for needle tip guidance)
• Ultrasound

ED Pericardiocentesis Kits

Procedure (Subxiphoid Approach)

• In ED the patient will often be arrested or peri arrest, if arrested consider ceasing compressions during the procedure to increase chance of success and reduce risk of ventricle injury. If patient is conscious, consider left decubitus if possible, but in most cases patient will be supine +/-C-spine.
• Sterilize and drape.
• In the conscious patient, infiltrate local anesthetic down to the pericardium
• ECHO to confirm probe position with visualization of largest pocket of fluid, often probe position is 3 or 12 o’clock position. Consider using an assistant for ECHO guidance.
• Connect 3 way tap, syringe and ECG probe to needle. If your needle has a stylet, insert through the skin with stylet in place, then remove stylet and connect the 3 way tap and ECG probe (reduces risk of tissue coring).
• Continue to insert needle in the direction of the left scapula tip, aspirate continuously. Stop when non-clotting blood or fluid is aspirated.
•  Place catheter into pericardium using Seldinger technique. Once position is optimized, connect tubing and allow further fluid to drain
• Watch for hemodynamic improvement and signs of contact with ventricle. ST elevation or ventricular ectopics signal contact with ventricle.

Complications

• Laceration of coronary artery or myocardium
• Pneumothorax
• Arrhythmias
• Liver or stomach injury
• Infection