CARDIOTHORACIC PROCEDURESA patient with breast cancer presents with a BP of 60/30, muffled heart
sounds, and distended neck veins. Cardiac monitor shows electrical
alternans. Which diagnostic test is indicated? Which therapeutic inter-
vention follows?
Cardiac ultrasonography to confirm pericardial effusion followed by pericar-
diocentesis.Pericardiocentesis
INDICATIONS
■ Hemopericardium
■ Pericardial effusion with tamponade
■ Pneumopericardium
CONTRAINDICATIONS
■ Relative: Immediately available definitive treatment modalities, ie, pericar-
dial window
TECHNIQUE
■ Use ultrasound guidance when available to identify greatest fluid collection.
■ Cardiac monitoring with defibrillator on hand during procedure
■ 7.5- to 12.5-cm 18-Ga needle or Intracath needle should be used.
■ Parasternal approach: Needle is inserted perpendicular to the skin in the
left fifth intercostal space. Insertion either just lateral to the sternum or
3–4 cm from the sternum should be used to avoid injury to the internal
mammilary artery.
■ Subxyphoid approach:Needle is inserted between the xyphoid process
and the left costal margin at a 30–45°angle to the skin aiming toward the
left shoulder (see Figure 19.1).
■ Parasternal approach has less chance of injury to right atrium but more
chance of lung injury compared to subxyphoid approach. During “blind”
pericardiocentesis, the subxyphoid approach is recommended.
■ An ECG lead attached to the needle will show a current of injury (typically
ST elevation) when the needle touches the ventricular wall. When this
occurs, withdraw the needle until the injury pattern is no longer present.
■ Needle will penetrate the pericardium about 6–8 cm beneath the skin in
adults and <5 cm in children.
■ Obtain CXR to evaluate for pneumothorax.
COMPLICATIONS
■ Failure to yield fluid (“dry tap”)
■ Myocardial injury possibly leading to hemopericardium
■ Coronary vessel laceration leading to myocardial infarction and/or
hemopericardium
■ Dysrhythmia
■ Pneumothorax
■ Pneumoperitoneum
PROCEDURES AND SKILLS