❤️ Chapter 145: Pericardiocentesis

Indications (cardiac tamponade – Beck's triad) · Subxiphoid approach · ECG guidance (ST elevation = myocardial contact) · Ultrasound guidance · Pericardial drain placement · Complications (coronary artery puncture, haemothorax, arrhythmia)

🔍 Core Concepts: Pericardiocentesis

📌 Indications
Emergent: cardiac tamponade (hypotension, distended neck veins, muffled heart sounds – Beck's triad). Non-emergent: diagnostic drainage (malignancy, infection), large effusion with respiratory compromise.
📍 Subxiphoid approach
Needle entry at angle of xiphoid and left costal margin, directed toward left shoulder (45° to skin, 45° off midline).
⚡ ECG guidance (emergency)
Connect alligator clip to V1 lead. ST elevation or injury pattern indicates needle contacting myocardium – withdraw immediately.
🩺 Ultrasound guidance (preferred)
Identify effusion (size, location), guide needle, avoid cardiac puncture. Apical or parasternal approach.
🔧 Seldinger technique for drain
Needle → guidewire → dilator → pigtail catheter. Connect to drainage system. Post-procedure CXR and echocardiogram.
⚠️ Complications
Coronary artery puncture, myocardial laceration, haemothorax, pneumothorax, arrhythmia, infection, false-negative (clotted blood), false-positive (intracardiac aspiration).
❌ Contraindications
Traumatic haemopericardium with unstable vital signs (relative – requires thoracotomy). Aortic dissection (relative). Severe coagulopathy.

🩺 Stepwise Pericardiocentesis (Subxiphoid Approach)

1
Identify cardiac tamponade
Beck's triad: hypotension, distended neck veins (JVP), muffled heart sounds. Pulsus paradoxus (>10 mmHg drop). Echocardiogram confirms (if stable).
2
Prepare patient & equipment
Supine, head elevated 30-45°. Continuous ECG, pulse oximetry. Ultrasound if available. Sterile prep. Local anaesthesia (if patient awake).
3
Needle insertion (subxiphoid)
Insert needle (18G spinal or pericardiocentesis needle) at angle of xiphoid and left costal margin. Aim toward left shoulder (45° to skin, 45° off midline). Advance slowly, aspirating continuously.
4
Confirm placement
Fluid return (pericardial fluid – does not clot; intracardiac blood clots). ECG guidance: ST elevation = myocardial contact – withdraw. Ultrasound visualisation.
5
Drainage & post-procedure
Withdraw as much fluid as possible. For ongoing drainage, place pigtail catheter (Seldinger technique). Send fluid for analysis (cell count, culture, cytology, LDH, protein). CXR to rule out pneumothorax/haemothorax. Repeat echocardiogram.