HWN Suggests

The Pericardiocentesis

So let's say you have a patient--maybe they have a history of malignancy or renal failure or lupus or whatever--and the patient's having some trouble. Let's say they're dyspneic and hypotensive, and round out the classic Beck's Triad with some muffled heart sounds and distended neck veins (although, like most eponymous triads and pentads, only 33% of patients actually have all three). You astutely throw your ultrasound on the chest...

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  How to Perform an US-Guided Pericardiocentesis

We see patients with pericardial effusions often in the emergency department. When those effusions are causing tamponade, a pericardiocentesis can be life-saving procedure. A few months ago, Dr. Plantin, PGY-2 EM resident at HUM, performed his first pericardiocentesis.

 Ultrasound-Guided Pericardiocentesis

All the years of ultrasound training in residency has paid off. You found the large pericardial effusion in the hypotensive patient who is still alive, but looks sick. You are a star! The only problem was that you never performed a pericardiocentesis in an awake patient. The cardiology fellow is at home sleeping and/or the closest receiving hospital is about 1 hour away. Now what?

Articles of Interest

The Blind Approach

This method may still be employed if an ultrasound machine is not available, but ultrasound-guided pericardiocentesis is the recommended safe method to perform this procedure. The pericardium lies about 2-3cm below the skin in the average adult. A 16-18 gauge needle attached to a large syringe should be used and the chest wall should be cleaned and draped using accepted sterile techniques. The needle should be inserted at the xiphoid process up into the chest at a 45° angle and directed towards the tip of the left scapula. The syringe should be aspirated as the needle is advanced every 1-2mm until fluid is aspirated. The operator should feel the needle penetrate through the pericardium. If immediate thoracotomy is not possible a catheter can be advanced using the Seldinger technique over a wire into the pericardial space and left in place to allow for continuous drainage.

A Novel, Low-cost, Low-fidelity Pericardiocentesis Teaching Model

Pericardiocentesis is a high-risk/low-frequency procedure important to emergency medicine (EM). However, due to case rarity it is not often performed on a patient during residency training.

Best Case Ever 31: Emergency Pericardiocentesis

On this EM Cases Best Case Ever, Andrew Sloas, the brains behinds the fabulous PEM-ED podcast tells the tale of an emergency pericardiocentesis gone bad and what he learned from it. Emergency pericardicentesis can be life saving, but it also carries risks. Dr. Sloas reviews the steps to take to ensure that the pericardiocentesis needle is the the correct place to minimize the risk of intubating the right ventricle of the heart.

Central Lines, Surgical Airways and Pericardiocentesis

Consider pericardial effusion with tamponade in any patient with unexplained SOB. Tamponade is a clinical diagnosis with ultrasound helping to confirm! Our experts recommend an apical approach, with U/S.

Emergency Pericardiocentesis

Animation by Cal Shipley MD

Knife or the needle that is the question? Pericardiocentesis vs Pericardial Window Pros and Cons

Pericardiocentesis and pericardial window are commonly performed procedures which may lead to complications such as infection, bleeding, perforation of a ventricle, laceration of a coronary artery, pneumothorax, and death. Numerous case reports have described the development of cardiogenic shock, pulmonary edema...

Pericardiocentesis technique

Only 25% of candidates passed that question. This is consistent with the expected level of experience of this procedure. Judging by a brief Google search, much of the modern literature on this topic is concerned with harping on about how great it is that this dangerous procedure is dying out, being replaced by safer ultrasound-guided methods.

Pericardiocentesis: ultrasound guidance is essential

Ultrasound-guided pericardiocentesis is simple, safe and effective, and should replace the blind technique. This procedure should be part of the armamentarium of ultrasound-guided practices of emergency or critical care physicians.

What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance?

Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach. The distance from skin to fluid collection is the least in both of these views.

Resources

EM in 5

Dr. Cameron Kyle-Sidell from the EM Residency in Mirebalais, Haiti, is back with an other fantastic video! This time on parasternal pericardiocentesis, demonstrated in real-time by one of the residents!

Life in the Fastlane

Pericardial blood doesn’t clot...

NUEM Blog

Given the urgency of the situation and severity of the patient’s clinical status, blind insertion of a needle into the pericardial space using anatomic landmarks has historically been the method of choice to restore hemodynamic stability. The availability of bedside ultrasound in many emergency departments more recently has led many physicians to pursue an image-guided pericardiocentesis. Various studies have demonstrated decreased mortality and morbidity with an ultrasound-guided approach when compared to a blind approach. However, depending on the clinical context and tools available, a blind approach may be the optimal choice.

Taming the SRU

First, pericardiocentesis should be considered a temporizing procedure. Let’s take a look at how to perform a pericardiocentesis with our 2-part video series.

WikEM

If ultrasound not available: Wire with alligator clip connected to base of needle and cardiac monitor or precordial EKG lead

StatPearls

There are no absolute contraindications to pericardiocentesis. Even withdrawal of a small amount of fluid in a very unstable patient can lead to an immediate improvement in hemodynamics. Relative contraindications include uncorrected coagulopathy, low platelet count, and lack of knowledge about the anatomy of the chest.