Pericardiocentesis

Patients with cardiac tamponade following trauma require an urgent thoracotomy. If this is not immediately available, pericardiocentesis might be considered as a temporising measure, however it will not address the cause of bleeding and the patient will rapidly destabilise again.

 

Indications

Traumatic cardiac tamponade and thoracotomy not an immediate option

 

Contraindications

Pericardial effusion without signs of tamponade and vital signs stable

 

Equipment

• PPE
  • Gown, gloves, mask, eye protection
• Drapes
• Antiseptic solution
  • Eg: betadine or chlorhexidine
• 1% lignocaine 5ml
  • 5ml syringe for LA
  • Drawing up needle
  • 25G needle for skin infiltration, 22G needle for deeper infiltration
• Pericardiocentesis needle or 18-22G LP cutting needle
• 20ml syringe and 3 way stop-cock
• Ultrasound (curvilinear or echo probe) with sterile gel and cover

 

Procedure

1. Ideally patient reclined at 30 degrees
2. Don PPE
3. Chosen site is prepped with antiseptic solution and skin infiltrated with local anaesthetic

 

There are several approaches. Ultrasound guidance is recommended in all cases

The needle is advanced in plane with the operator aspirating the syringe until blood is obtained.

 

1. Subxiphoid

The traditionally taught approach

Ultrasound is placed in the subxiphoid position

The needle is inserted between the xiphoid process and left subcostal margin at 45 degrees, aiming up towards the tip of the scapula

 

2. Apical

Ultrasound is placed in the apical position

Insert needle at the apex (5^th intercostal space, midclavicular line) aiming towards the right shoulder

 

3. Parasternal view

Advantage of avoiding the liver and lung but can lacerate the internal mammary artery

Ultrasound is placed in the parasternal long view position

Insert needle adjacent to the probe perpendicular to skin in the 4^th or 5^th intercostal space just lateral to the sternum

 

Complications

• Myocardial injury
• Coronary artery or inferior mammary laceration
• Precipitation of arrhythmia
• Liver laceration
• Pneumothorax