EMERGENCY DEPARTMENT · WALL POSTER

Pericardiocentesis

NOT YET REVIEWED BY A CLINICIAN. Written for this site and cited, but nobody has read it line by line. Check it against your own practice before you use it.

STEPS · ◆ KEY STEP — LOGGED WITH ITS TIME

DECIDE — IS IT TAMPONADE, AND IS THIS THE RIGHT PROCEDURE

Traumatic tamponade in arrest needs a thoracotomy, not a needle. If this is penetrating trauma or a traumatic arrest, leave this card and run Traumatic Cardiac Arrest.
Tamponade is an echo diagnosis: effusion, right ventricular diastolic collapse, a plethoric IVC that does not vary — in a patient who is shocked.
Beck’s triad is late and often absent.
Say out loud what you are seeing on the screen and that you are draining it. ◆ TAMPONADE CONFIRMED ON ECHO
Start the transfer conversation in parallel — draining is temporary; it does not treat the cause.
A small effusion that has collected fast tamponades; a large chronic one may not.

SET UP — THE ULTRASOUND CHOOSES THE WINDOW

There is no pericardiocentesis tray in this department. Two ways to do it with what is stocked — pick one before you scrub.
Option A — the Central Line Kit (Room 7 · Vascular Access). Its introducer needle and wire let you rail a catheter into the sac, so you can leave a drain. Take this one if the effusion is likely to come back.
Option B — an 18 G spinal needle on a 20 mL syringe with a three-way stopcock. One long needle, aspirate and withdraw, nothing left behind. Faster to set up; no drain at the end of it.
Scan first, then decide. Find the largest pocket that is closest to the skin and free of lung and liver, and note its depth.
Use the window where the fluid is — subxiphoid, parasternal or apical.
Sit the patient up to about 30–45° if they will tolerate it; the effusion moves toward where you are going.
Sedation and positive pressure can arrest a tamponade patient — both drop the preload this heart depends on. Drain first if you can.
Prep the skin, sterile probe cover, local anesthetic if there is time.

DRAIN

Advance under real-time ultrasound, aspirating and watching the needle tip the whole way in.
Fluid returns — stop advancing. Hold the needle absolutely still and stabilize your hand on the patient. ◆ PERICARDIAL FLUID ASPIRATED
If unsure whether you are in the pericardium or the ventricle, inject agitated saline — bubbles in the pericardium confirm the correct location.
Blood that clots in the syringe is usually ventricular. Pericardial blood is defibrinated and does not clot.
Withdraw fluid and reassess as you go — 20–50 mL is often enough to bring back a pulse and a pressure.
If you used the Central Line Kit: pass a catheter over the wire and secure it. If you used the spinal needle: aspirate to effect and withdraw. Re-accumulation is expected — if a catheter is in, do not pull it out. ◆ DRAIN SECURED

AFTER

Re-scan: is the right ventricle filling, is the IVC less plethoric, is the pressure up? Judge the result by the echo, not by the volume in the syringe.
Send the fluid — cell count, cytology, culture, and hematocrit against the patient’s own.
Look for what you may have caused: pneumothorax, myocardial or coronary injury, arrhythmia, liver injury. Chest film and a rhythm strip.
Sudden decompensation afterwards is re-accumulation until proven otherwise. Re-scan before anything else.
Hand over the depth you went to, the window you used, how much came out and what it looked like.

FIGURE

Buys minutes. It is a bridge to drainage, not the fix.

PITFALLS

Landmarks instead of ultrasound when an ultrasound is available.

Sedating or intubating first. Both reduce the preload this patient depends on.

Draining a big chronic effusion that is not tamponading. The indication is tamponade physiology, not effusion size.

Pulling the catheter once the pressure comes up. The effusion re-accumulates.

Treating a traumatic tamponade with a needle, traumatic pericardial tamponade requires a thoracotomy.