- Alan C Heffner, MD
Alan C Heffner, MD
- Director of Critical Care
- Director of ECMO Services
- Pulmonary and Critical Care Consultants
- Department of Internal Medicine
- Department of Emergency Medicine
- Carolinas Medical Center
- Associate Clinical Professor
- University of North Carolina School of Medicine
- Section Editors
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Pericardial effusion and cardiac tamponade represent a spectrum of disease with wide variation in clinical presentation [1,2]. While all significant pericardial effusions are of clinical importance, emergency drainage is needed only for patients with hemodynamic compromise. Cardiac tamponade with hemodynamic collapse is an absolute indication for emergent pericardial drainage via pericardiocentesis or surgical pericardiotomy.
The lethality of pericardial effusions has been recognized for centuries. Riolanus suggested sternal trephination to release pericardial fluid in 1653 and the Spanish physician Romero described intercostal surgical drainage in the early 19th century . The Viennese thoracic surgeon Franz Schuh performed the first successful blind pericardial aspiration in 1840 via a left parasternal approach . Marfan later described the subxiphoid technique in 1911 . Despite significant complications and safety concerns, this remained the standard approach for blind pericardiocentesis through the late 20th century. Experience with echocardiography-directed pericardiocentesis paralleled technical advances in ultrasound during the 1970s, and has evolved as the procedure of choice due to its improved safety and efficacy [6-9]. Nonetheless, blind subcostal or parasternal pericardiocentesis remains a standard procedure for emergency pericardial drainage when ultrasound guidance is unavailable.
The indications, contraindications, preparation, equipment, and techniques of emergency pericardiocentesis will be reviewed here. Cardiac tamponade and its related diseases and non-emergent pericardiocentesis are discussed separately. (See "Cardiac tamponade" and "Cardiac injury from blunt trauma" and "Constrictive pericarditis" and "Pericardial disease associated with malignancy" and "Diagnosis and treatment of pericardial effusion", section on 'Pericardial fluid drainage'.)
ANATOMY AND PHYSIOLOGY
The parietal pericardium is a fibrous sac that encloses the heart and the roots of the great vessels (figure 1). The cone-shaped sac rests on the diaphragm and fuses superiorly with the adventitia of the great vessels. The pericardium and heart lie between the pleural sacs. The pericardium is fixed within the thorax by attachments to the anterior diaphragm, the sternum, and the fourth and fifth left costal cartilages. The phrenic nerve innervates the pericardium as its runs between the mediastinal pleura and fibrous pericardium.
In health, the pericardium envelops the heart loosely, but is rigid enough to provide stability within the thoracic cavity and to limit cardiac distention (pericardial constraint). The normal pericardial space contains <50 mL of thin serous lubricating fluid that is an ultrafiltrate of plasma. Lymphatic drainage of the pericardium to mediastinal and tracheobronchial lymph nodes provides the anatomic basis for pericardial involvement in the pathology of these regions.
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- ANATOMY AND PHYSIOLOGY
- MONITORING AND PREPARATION
- TECHNIQUE OVERVIEW
- General preparation
- Selecting the approach for pericardiocentesis
- - Subcostal (subxiphoid)
- - Parasternal
- - Apical
- Ultrasound-guided pericardiocentesis technique
- Pericardiocentesis technique without ultrasound guidance
- Intrapericardial needle confirmation
- Drain placement
- Catheter drainage and care
- SUMMARY AND RECOMMENDATIONS