A little fun fact about me is that I frequently wake up at 3, 4 or 5 in the morning in a cold sweat from some sort of vivid nightmare. The nightmares can vary from having a hot pink wedding dress that doesnt fit me, to having to do a pericardiocentesis on a patient who is wide awake asking me if I have ever performed one before, as he is actively tamponading in front of me. I figured I would do a short series of deep diving as a way to soothe my own anxieties in an effort to get better sleep, so without further ado, lets take a look at pericardiocentesis.
Now I had weeks of nightmares, followed by a sim session on pericardiocentesis before I came face to face with a real one.I had the great fortune of working a Northside shift with the wonderful Dr. Errel Khordipour- who if you didn't know is the local pericardiocentesis expert. The man has done probably 600 at this point, (I am kidding- I think its closer to 30? Cue Errel rolling his eyes), and as the story goes, I was being a nosey nancy and once again butted my way into the resus bay- this time with Dr. Mark Calandra when Mark expertly intubated a gentleman who was boarding in the ED who decompensated on the wall. The patient shortly after being intubated, coded. While we were doing compressions, Errel did what he does best- threw a probe on this mans chest to find a large pericardiocentesis and well there you have it, the mans 1000th pericardiocentesis.
Pericardiocentesis:
Indication: Pericardial effusion which is an accumulation of fluid between the visceral and parietal layers of the pericardium, this can reduce the heart's ability to fill or empty appropriately
Cardiac Tamponade: when the fluid accumulation occurs so quickly there is significant impairment of the filling of the right ventricle
This requires an emergent or urgent procedure and consider performing in the ED
Confirm on ultrasound which should present with:
Right atrial collapse > ⅓
Early right ventricular diastolic collapse
Can be done Emergently or Urgently
Emergent: patient is in cardiac arrest or peri arrest and there are no other sources for the patients instability
Urgently: consider the etiology of the pericardial effusion (infections, reactive, related to fluid overload)
Performing the procedure:
Can be done blind or ultrasound guided
Blind:
Use a subxiphoid approach
Clean the area, consider local anesthetic if the patient is not in cardiac arrest
Using an 18 gauge spinal needle on a 20 cc syringe, insert the needle 1 cm between the left costal arch and xiphoid process
Angle the needle at ~20 degrees pointed towards the left shoulder, slowly advancing while withdrawing on the plunger
Aspirate enough fluid to allow for clinical improvement
Ultrasound guided:
Using the ultrasound to find the largest window with effusion
Insert the needle in the plane with the largest window
With ultrasound you have the freedom to do this subxiphoid, apical, suprasternal, or parasternal
Walk the tip of the needle with the ultrasound
Once inside the pericardial window, you can remove the syringe and using Seldingers technique, thread a wire into this space, followed by a dilator, and then a pigtail catheter, allowing more continuous drainage from this effusion
Complications to consider:
My greatest fear is always that I spear the ventricle and essentially create a pigtail into the ventricle that I just pour blood from the ventricle out into the world
Other fears to add onto this include hitting other large vessels (mammary arteries, intercostal arteries), causing a pneumothorax, liver or peritoneal injuries, infection or death
If you are performing a pericardiocentesis in the ED, these patients have an extremely high mortality rate, however this can be a lifesaving measure that could potentially change the outcome for your patient
So I will leave us there, but now you will be better prepared the next time your unstable, chest pain patient decompensates on the wall to grab the spinal needle and perform a pericardiocentesis and save your patient's life!
Until next time! Sweet Dreams!
Your admin resident,
Kaitlyn
References;
Tewelde S. Pericardiocentesis. In: Swadron S, Nordt S, Mattu A, and Johnson W, eds. CorePendium. 5th ed. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recWedjPB7rstCdug/Pericardiocentesis#h.hxonuesemkf2. Updated December 7, 2021. Accessed March 12, 2025.
Willner DA, Shams P, Grossman SA. Pericardiocentesis. [Updated 2025 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470347/