II. Indications

III. Contraindications: Emergency Pericardiocentesis

  1. Pericardial Effusion with stable Vital Signs and no sign of Cardiac Tamponade

IV. Precautions

  1. Do not delay Pericardiocentesis in Cardiac Tamponade
    1. Dyspnea, Tachycardia, Hypotension progress rapidly to Cardiac Arrest
  2. Traumatic Pericardial Effusion (Penetrating Trauma)
    1. Pericardiocentesis may temporize but does not supplant Emergency Thoracotomy
    2. Emergency Thoracotomy is the treatment of choice for Penetrating Trauma with application pressure on heart wound
    3. Pericardiocentesis for Penetrating Trauma is unlikely to relieve tamponade (as bleeding will continue until wound is repaired)

V. Imaging: Ultrasound

  1. Transducer: 2.5-3.5 MHz with indicator pointed to patient's right side
  2. Guide Pericardiocentesis needle (see below)
  3. Confirm Cardiac Tamponade
    1. See Pericardial Effusion
    2. Right atrium collapses in systole
    3. Right ventricle collapses in diastole
    4. Vena cava dilated without respiratory variation in size

VI. Preparation

  1. Identify landmark based on approach
    1. Identify window with greatest pocket of fluid (sub-xiphoid, apical or parasternal)
    2. Safest Ultrasound-guided window is often the apical window (Pericardium is closest to skin at apex)
      1. Identify window with pocket of fluid with only pericardial pocket and not heart in-line with needle approach
  2. Apply sterile probe cover (if no delays)
  3. Prep region with antiseptic (e.g. hibiclens) and drape
  4. Local anesthetic with Lidocaine 1% (conscious patient, if no delays)
    1. Eliminate any bubbles from the syringe as these will interfere with Ultrasound visualization
    2. Consider saline in syringe to inject into pericardial sac to visualize small bubbles floating in fluid (confirms position)
  5. Consider raising head of bed to 30 degrees to better localize effusion (non-arrest, relatively stable patients only)
  6. Prepare needle and syringe
    1. Needle 16-18 gauge, 6 inch (15 cm)
    2. Syringe 20-35 cc with 3 way stop-cock attached
  7. General technique pointers
    1. Observe while threading guidewire into pericardial sac to confirm not in ventricle

VII. Technique: Apical Approach (preferred Ultrasound approach)

  1. See Preparation above
  2. Position Ultrasound to apical view
  3. Needle is inserted adjacent to Ultrasound probe
    1. Insert needle at Ultrasound probe oriented toward cardiac apex (towards the right Shoulder)
    2. Aspirate while inserting needle
    3. Watch the needle enter the largest pocket of fluid and aspirate Pericardial Effusion

VIII. Technique: Sub-Xiphoid Approach

  1. See Preparation above
  2. Position Ultrasound in sub-xiphoid position
    1. EKG monitoring may be used if Ultrasound is not available
  3. Needle is inserted adjacent to Ultrasound probe
    1. Angle the needle at 45 degrees, and directed towards the left Shoulder
    2. Aspirate while inserting needle
    3. Watch the needle enter the largest pocket of fluid
      1. Aspirate Pericardial Effusion

IX. Technique: Parasternal Approach (PLAX View)

  1. Precaution
    1. Left anterior descending artery may be lacerated when approaching Pericardium from this view
  2. Position Ultrasound lateral to needle entry site
  3. Insert needle perpendicular to chest (90 degrees)
    1. Fifth intercostal space
    2. Immediately lateral to Sternum
  4. Aspirate while inserting needle
  5. Watch the needle enter the largest pocket of fluid
    1. Aspirate Pericardial Effusion

X. Technique: EKG Monitoring (if Ultrasound not available)

  1. Sudden ST Elevation on EKG (current of injury) suggests needle contact with Myocardium
  2. Withdraw needle slightly if ST Elevation occurs
  3. ST Elevation that persists should prompt complete needle removal

XI. Technique: Post-aspiration

  1. Consider replacing needle with 14-gauge flexible catheter using seldinger technique
  2. Follow-up Chest XRay following Pericardiocentesis to evaluate for complications
  3. Consult thoracic surgery for definitive care

XII. Resources

  1. Pericardiocentesis Video (NEJM)
    1. http://www.youtube.com/watch?v=BQTVqUPimdk

XIII. References

  1. (2008) ATLS, p. 109
  2. Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete's Beach
  3. Orman, Dawson and Mallin in Majoewsky (2013) EM:Rap 13(1): 4-6

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Ontology: Pericardiocentesis (C0191234)

Definition (NCI) The aspiration of excess fluid between the pericardium and the heart. (ACC)
Definition (NCI_CDISC) The aspiration of excess fluid between the pericardium and the heart.
Definition (MSH) Surgical puncture of the pericardial cavity for the aspiration of fluid. (Dorland, 28th ed)
Concepts Therapeutic or Preventive Procedure (T061)
MSH D020519
ICD9 37.0
ICD10 38406-00
SnomedCT 8495002, 175179007, 309849004
CPT 33011, 33010, 1006059
English Pericardiocentesis, Pericardiocenteses, pericardiocentesis, pericardiocenteses, PERICARDIOCENTESIS, Pericardiocentesis (procedure), Pericardiocentesis, NOS, Pericardiocentesis (procedure) [Ambiguous]
Dutch pericardiocentese, Pericardiocentesis
German Perikardiozentese, Herzbeutelpunktion, Perikardpunktion
Japanese 心膜穿刺, シンマクセンシ
Swedish Perikardiocentes
Czech perikardiocentéza, Perikardiocentéza
Finnish Perikardiosenteesi
French Ponction du péricarde, Ponction péricardique, Péricardiocentèse
Russian PERIKARDA PARATSENTEZ, PARATSENTEZ PERIKARDA, ПАРАЦЕНТЕЗ ПЕРИКАРДА, ПЕРИКАРДА ПАРАЦЕНТЕЗ
Polish Nakłucie jamy osierdzia, Perikardiocenteza
Hungarian Pericardiocentesis
Norwegian Perikardiocentese
Spanish pericardiocentesis (concepto no activo), pericardiocentesis (procedimiento), pericardiocentesis, Pericardiocentesis
Italian Pericardiocentesi
Portuguese Pericardiocentese

Ontology: Ultrasonic guidance for pericardiocentesis (C0203399)

Concepts Diagnostic Procedure (T060)
SnomedCT 1787006
CPT 76930
English ultrasonic guidance for pericardiocentesis, ultrasonic guidance for pericardiocentesis (procedure), ECHO GUIDE CARDIOCENTESIS, Echo guide cardiocentesis, Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation, US GUIDANCE PERICARDIOCENTESIS RS&I, Ultrasonic guidance for pericardiocentesis, Ultrasonic guidance for pericardiocentesis (procedure)
Spanish guía ecográfica para pericardiocentesis (procedimiento), guía ecográfica para pericardiocentesis