Emergency War Surgery NATO Handbook: Part II: Response of the Body to Wounding: Chapter IX: Shock and Resuscitation

Pericardiocentesis

United States Department of Defense

Pericardiocentesis

1. Monitor the patient's vital signs, central nervous pressure (CVP), and ECG before, during, and after the procedure.

2. Prep the xiphoid and subxiphoid areas, if time allows.

3. Using a #16-18 gauge, 6-inch or longer over-the-needle catheter, attach a 35 ml empty syringe with a three-way stopcock.

4. Assess the patient for any mediastinal shift that may have caused the heart to shift significantly. This is best determined by noting the position of the palpable trachea and the point of maximal intensity of the apical heart beat.

5. Puncture the skin 1-2 cm interior to the left of the xiphichondral junction, at a 45° angle to the skin.

6. Carefully advance the needle cephalad and aim toward the tip of the left scapula.

7. If the needle is advanced too far (into the ventricular muscle) an injury pattern (e.g., extreme ST-T wave changes, or widened and enlarged QRS complex) will appear on the ECG monitor. This pattern indicates that the pericardiocentesis needle should be withdrawn until the previous baseline ECG tracing reappears. Premature ventricular contractions may also occur, indicating undesired needle contact with the ventricular myocardium.

8. When the needle tip enters the blood-filled pericardial sac, withdraw as much unclotted blood as, possible.

9. In a simple tamponade, the aspiration of pericardial blood will cause a rapid drop in the CVP and a slower improvement in the blood pressure,

10. As aspiration progresses and blood is withdrawn, the surface of the heart will reapproach the pericardial surface and the tip of the needle. An ECG injury pattern may reappear. This indicates that the pericardiocentesis needle should be withdrawn slightly. Should this injury pattern persist, withdraw the needle completely.

11. After aspiration is completed, leave the pericardiocentesis catheter in place with the stopcock closed. Secure the catheter in place.

12. Reassess all vital signs and the CVP. A full 12-lead ECG should also be done upon completion of this procedure.

13. Should cardiac tamponade persist, the stopcock may be reopened and the pericardial sac reaspirated. The plastic pericardiocentesis needle call be sutured or taped in place, and covered with a small dressing to allow for continued decompression en route to the hospital or the operating room.

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Operational Medicine 2001

Health Care in Military Settings

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