S4C37 - Pericardiocentesis

Question 1

Pericardial effusion: Diagnosis

Answer 1

• ECG: electrical alterans - alternating high/low QRS complexes as heart swings toward and away from the chest wall with each contraction
• non-specific ST-T wave changes or bradycardia

-echo: effusion, right-sided heart collapse, RA>RV

Question 2

Pericardiocentesis: contraindications

Answer 2

• absolute: aortic dissection

- relative: coagulopathy, thrombocytopenia, posterior loculated effusions

Question 3

Pericardiocentesis: risks/precautions

Answer 3

-blind approach: injury to liver, lung, diaphragm, GI tract, chamber puncture, myocardial damage, laceration of coronary vessels, arrhythmia

Question 4

Pericardiocentesis: positioning

Answer 4

• pt should be at 30-45 deg, however if arresting they will be supine
• place cardiac monitor, pulse ox, oxygen
• infiltrate with lidocaine if time
• identify max effusion with US and trajectory for needle
• most common approach is left chest wall (left parasternal or apical at the 5th intercostal space) or subxiphoid approach
• if left parasternal - go 3-5cm from sternal edge to avoid mammary artery, go over superior margin of rib
• sterile prep and drape
• insert needle under US guidance if possible, if effusion looks full of echogenic material the blood may be clotted and unable to aspirate
• if aspiration is too easy, suspect ventricular puncture
• send fluid for protein, cell count, gm stain, Cx

Question 5

Pericardiocentesis: blind subxiphoid approach

Answer 5

• prep
• freeze
• point of needle starts either directly below or adjacent to the xiphoid process
• 18g needle, insert at 45deg angle to the skin with tip directed to left or right shoulder
• complications: morbidity 20% with mortality at 6%
• vs US guided with complication rate