When hemodynamic compromise is present, infusion of a normal saline fluid bolus can be temporizing by improving right ventricular volume while preparations are made for emergency pericardiocentesis.1
The purpose of emergency pericardiocentesis is treatment of hemodynamic compromise from cardiac tamponade. Emergency pericardiocentesis is also indicated during resuscitation from PEA after other causes of PEA have been excluded.
Postoperative or penetrating trauma patients may develop tamponade 2 weeks or more after surgery.7 In one study of traumatic tamponade, the most common indications for pericardiocentesis were clinical tamponade (83%), with echocardiographic findings of ventricular diastolic collapse (69%) and right atrial collapse (33%).14 Pericardiocentesis for a traumatic effusion from penetrating cardiac trauma may be performed during resuscitation to stabilize a patient until surgery for definitive repair is available, but surgical drainage is preferred in traumatic effusions and purulent pericarditis.15 If the patient is hemodynamically compromised and on the verge of cardiac arrest, perform emergency pericardiocentesis in the ED, rather than delay treatment by transporting to the OR.
If bedside US is available, two-dimensional echocardiographic imaging is preferred to guide pericardiocentesis16,17,18,19 and can also evaluate the size of the effusion and its effect on cardiac output. The 2010 Focused Cardiac Ultrasound in the Emergent Setting guidelines state: "When emergency pericardiocentesis is indicated ultrasound can provide guidance by first imaging the fluid collection from the subxiphoid/subcostal or other transthoracic windows to define the best trajectory for needle insertion."20 The guidelines further emphasize that bedside US results in fewer complications and greater success in performance of pericardiocentesis.20 The European Society of Cardiology's 2004 Guidelines on the Diagnosis and Management of Pericardial Disease has evidence-based guidelines on pericardiocentesis. Pericardiocentesis is lifesaving in cardiac tamponade (level of evidence B, Class I indication) and indicated in effusions >20 mm in echocardiography but also in smaller effusions for diagnostic purposes (pericardial fluid and tissue analyses, pericardioscopy, and epicardial/pericardial biopsy; level of evidence B, Class IIa indication). American College of Cardiology/American Heart Association 2005 guidelines for the use of echocardiography gives Class I recommendations to using this methodology for visualizing effusions and detecting hemodynamic compromise secondary to tamponade. The European Society of Cardiology 2004 guidelines recommend that practitioners use US guidance rather than blind approaches and the ECG-alone guided approach for pericardiocentesis.21 Using echocardiographic-guided pericardiocentesis reduces radiation associated with fluoroscopy and allows the procedure to be performed safely at the bedside.22
CONTRAINDICATIONS TO PERICARDIOCENTESIS
Some authors list aortic dissection as an absolute contraindication. Relative contraindications include uncorrected coagulopathy, anticoagulant therapy, thrombocytopenia, and small posterior loculated effusions.
Traditional blind subxiphoid approaches increase risk of damage to adjacent structures, such as the liver, lung, diaphragm, and GI tract. The cardiovascular system may also sustain injuries during the procedure, including chamber puncture, myocardial damage, and laceration of coronary arteries/veins. Resultant arrhythmias may develop as well, secondary to myocardial damage. Although risks must be considered, use of specific techniques and imaging can significantly reduce injury from the procedure itself. If bedside US is not available and the patient has cardiac or hemodynamic compromise, the blind subxiphoid approach for cardiac tamponade for acute hemopericardium can be used.23 See Table 34-2 for a list of equipment needed.
TABLE 34-2Equipment for Emergency Pericardiocentesis ||Download (.pdf) TABLE 34-2 Equipment for Emergency Pericardiocentesis
Antiseptic (e.g., povidone-iodine, ChloraPrep)
Local anesthetic (1%–2% lidocaine)
25-gauge needle, 5/8 in. long
18-gauge catheter-type needle, 11/2 in. long (for parasternal or apical approaches)
Syringes (10, 20, and 60 mL)
4 ×4 gauze squares
Collection system or basin
Sterile US probe cover (can be sterile glove)
Yankauer suction catheter
18-Gauge spinal needle 31/2 in. long (if needed for subxiphoid blind approach)
Alligator clips connected by wire (for ECG approach)
Variable angle needle guide attachment for US
#11 scalpel blade
J-tipped guidewire 0.035 mm diameter
6F–8F pigtail catheter
PATIENT PREPARATION AND POSITIONING
If time and conditions permit, obtain and review a stat portable chest x-ray to identify mediastinal shift or pneumothorax. Traditional positioning for pericardiocentesis is with the head of the bed elevated to approximately 30 to 45 degrees, but in cardiac arrest or near-arrest, this position may not be feasible. Therefore, the procedure is often performed with the patient supine. Before choosing the needle insertion site, it must be noted if the patient has mediastinal shift, as this can displace structures and alter normal anatomic locations. In some instances, very small effusion volumes (50 to 100 mL) precipitate cardiac tamponade, and therefore, fluid may collect in dependent portions of the pericardial space. If the size of the effusion is small, rolling a patient to the left lateral decubitus position allows fluid to collect around the apex and provides easier access. This positioning also allows the left lung to move laterally, thereby increasing cardiac exposure.
ANESTHESIA AND MONITORING
Patients undergoing emergency pericardiocentesis in the ED are often in significant distress and are being resuscitated. They may therefore already be sedated or paralyzed, or both. If local anesthesia is needed, immediately before the procedure, administer 1% to 2% lidocaine SC and along the plane of expected needle insertion. Aspirate during infiltration to avoid injection of lidocaine directly into vascular structures.
Institute cardiac monitoring and pulse oximetry, and provide supplemental oxygen. Assistants can monitor the pulse amplitude.