Emergency Pericardiocentesis

imagesPericardial tamponade with hemodynamic decompensation


imagesPulseless electrical activity with clinical suspicion of tamponade or with ultrasonographic evidence of pericardial effusion


CONTRAINDICATIONS



imagesNone for the unstable patient


imagesCoagulopathy is a relative contraindication


RISKS/CONSENT



imagesIn the emergent situation no consent is required. Consent is implied.


imagesFor risks, see “Complications” section below


LANDMARKS



imagesAnatomic Approaches


   imagesSubxiphoid


      imagesNeedle is inserted between the xiphoid process and the left costal margin in a 30- to 45-degree angle to the skin


      imagesRecommendations regarding needle aim vary widely, including right shoulder, sternal notch, and left shoulder


   imagesParasternal approach (more common with bedside ultrasonography)


      imagesNeedle is inserted perpendicular to the skin in the left fifth intercostal space immediately lateral to the sternum


   imagesUltrasound-guided approach


      imagesPlace a 3.5- to 5.0-MHz probe in the subcostal position to directly visualize both the area of maximal effusion and location of vital structures


     imagesInsert needle in the left chest wall using a parasternal approach where the largest pocket of fluid is seen



imagesGeneral Basic Steps


   imagesSemiupright position


   imagesLocal analgesia


   imagesSterilize local area


   imagesInsert 18-gauge spinal needle


   imagesAspirate while advancing


TECHNIQUE



imagesPatient Preparation


   imagesA 100% oxygen via face mask should be administered if patient is conscious and nonintubated. Consider transiently decreasing tidal volume by 10% to 15% for intubated patients.


   imagesEnsure continuous cardiac and pulse oximetry monitoring


   imagesPatient should be placed in the semiupright position (15–30 degrees) if possible to pool pericardial fluid dependently


   imagesIf the patient is awake, local analgesia should be utilized


   imagesSterilize locally with chlorhexidine or povidone–iodine solution, and use sterile gloves and universal precautions


imagesProcedural Steps


   imagesAttach an 18-gauge spinal needle to a 10- to 30-mL syringe


   imagesAttach an alligator clip to the base of the needle and the other end to the precordial (V) lead of the electrocardiogram (ECG) machine to monitor for ST elevations indicating penetration of the myocardium (FIGURES 10.110.3)


   imagesUsing either a subxiphoid or parasternal approach (see “Landmarks” section above for details), insert and advance the spinal needle while gently aspirating the syringe, preferably with ultrasonographic assistance



images


FIGURE 10.1 Attaching an ECG lead to the pericardiocentesis needle will allow you to identify when the needle contacts the ventricular wall. (From Reeves SD. Pericardiocentesis. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:780, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Emergency Pericardiocentesis

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