Anatomy
Thorax
A 21 year old man is brought to ED having been involved in a road traffic accident. He is hypotensive with muffled heart sounds and distended neck veins. Your consultant suspects cardiac tamponade and proceeds to perform emergency pericardiocentesis. Which of the following sites is the needle best placed to relieve the tamponade:
Answer:
ATLS guidance recommends that a needle should be inserted into the pericardial cavity 1 - 2 cm inferior and to the left of the xiphochondral junction (between the xiphisternum and the left costal margin) at a 45 degree angle and advanced aiming toward the tip of the left scapula. The left fifth intercostal space in the midclavicular line is an alternative site used.Pericardial Aspiration
Anatomy / Thorax / Heart and Pericardium
Last Updated: 1st July 2020
Pericardiocentesis is a surgical puncture of the pericardial cavity for the aspiration of fluid, which is necessary to relieve the pressure of accumulated fluid in the heart.
Procedure
A needle is inserted into the pericardial cavity 1 - 2 cm inferior to the left of the xiphochondral junction (between the xiphisternum and the left costal margin) at a 45 degree angle and advance aiming toward the tip of the left scapula (site marked by cross in image below).
![Modified by FRCEM Success. Original by Mikael Häggström (See above. All used images are in public domain.) [Public domain], via Wikimedia Commons](https://mrcemsuccess.com/wp-content/uploads/2017/01/Surface-marking-heart-2-718x1024.png)
Site of Pericardial Aspiration. (Image modified by FRCEM Success. Original by Mikael Häggström [Public domain], via Wikimedia Commons)
Complications
Complications of pericardiocentesis include:
- Aspiration of ventricular blood instead of pericardial blood
- Laceration of ventricular epicardium or myocardium
- Laceration of coronary artery or vein
- Ventricular fibrillation
- Pneumothorax secondary to lung puncture
- Puncture of great vessels with worsening pericardial tamponade
- Mediastinitis secondary to oesophageal puncture
- Peritonitis secondary to peritoneal puncture
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
