Pericardial tamponade with hemodynamic decompensation

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

CONTRAINDICATIONS

 None for the unstable patient

 Coagulopathy is a relative contraindication

RISKS/CONSENT

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

 For risks, see “Complications” section below

LANDMARKS

 Anatomic Approaches

    Subxiphoid

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

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

    Parasternal approach (more common with bedside ultrasonography)

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

    Ultrasound-guided approach

       Place 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

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

TECHNIQUE

 Patient Preparation

    A 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.

    Ensure continuous cardiac and pulse oximetry monitoring

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

    If the patient is awake, local analgesia should be utilized

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

 Procedural Steps

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

    Attach 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 10.1–10.3)

    Using 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

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