**7. Pericardiocentesis**

Pericardiocentesis is the aspiration of fluid from the pericardial space that surrounds the heart. This procedure can be lifesaving in patients with cardiac tamponade, even when it complicates acute type A aortic dissection and when cardiothoracic surgery is not available.

#### **7.1. Indications**

#### *7.1.1. Emergent pericardiocentesis*

Life-threatening hemodynamic compromise due to suspected cardiac tamponade. Cardiac arrest secondary to cardiac tamponade.

#### *7.1.2. Nonemergent pericardiocentesis*

Diagnostic pericardiocentesis for pericardial effusions (due to infectious, hemorrhagic, or malignant etiology).

#### *7.1.3. Contraindications*

There is no absolute contraindication to pericardiocentesis in hemodynamically unstable patient.

#### *7.1.3.1. Relative contraindications*


Equipment needed: Essential equipment includes the following:


#### *7.1.4. Technique*

Ideally, patient should be in a semirecumbent position at 30–45 degrees so as to bring the pericardium close to the anterior chest wall; however, supine position is an acceptable alternative.

If time and situation allow, the procedure should be explained to the patient and local anesthesia should be administered at the site of procedure. Ensure IV access, with patient connected to the monitor, and supplemental oxygen. Ideally the procedure should be done under ultrasound guidance; however, if the patient is in cardiac arrest, then the procedure should be

There are various anatomical approaches for pericardiocentesis, as shown in the **Figure 7**, with subxiphoid approach and left parasternal margin being the most common sites (**Figure 8**).

In subxiphoid approach, mark the area between the xiphoid process and left sternocostal margin, ideally 1 cm inferolaterally to the xiphoid process on the left side. Clean the area using an antiseptic solution and insert the needle (spinal needle) at 30–45degrees, aiming toward the

an ECG machine, and use bedside ultrasound to visualize the needle tip in the pericardial as

Apply constant negative pressure on the syringe until a return of fluid or blood is visualized,

Stabilize the needle and withdraw as much fluid as possible. If a catheter-over-the-needle has been used, then the needle can be removed and catheter can be stabilized to the chest wall,

The needle may move closer to the myocardium, and an injury pattern may appear on the ECG, in which case the needle should be withdrawn slightly to avoid myocardial injury.

**Figure 8.** Needle insertion: Insert the spinal needle through the skin incision directed toward the left shoulder at a

45-degree angle to the abdominal wall and 45 degrees off the midline sagittal plane.

lead of

81

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If time permits, connect an alligator clip from the base of the spinal needle to the V<sup>1</sup>

cardiac pulsations are felt, or abrupt change in ECG waveform is noted (**Figure 10**).

with a three-way stopcock attached to allow continuous drainage of pericardial fluid.

initiated as soon as possible for pericardial fluid aspiration.

left shoulder, as shown in the picture.

depicted in **Figure 9**.

**Figure 7.** Various anatomical approaches for pericardiocentesis. Pericardiocentesis needle insertion sites. The subxiphoid and left sternocostal margins are the most commonly used sites (black dots).(Source: Medscape).

If time and situation allow, the procedure should be explained to the patient and local anesthesia should be administered at the site of procedure. Ensure IV access, with patient connected to the monitor, and supplemental oxygen. Ideally the procedure should be done under ultrasound guidance; however, if the patient is in cardiac arrest, then the procedure should be initiated as soon as possible for pericardial fluid aspiration.

Equipment needed: Essential equipment includes the following:

• Needles, 18 ga, 1.5 in and 25 ga, 5/8 inand • Spinal needle, 18 ga, 7.5–12 cm

lead of ECG machine

Ideally, patient should be in a semirecumbent position at 30–45 degrees so as to bring the pericardium close to the anterior chest wall; however, supine position is an acceptable

**Figure 7.** Various anatomical approaches for pericardiocentesis. Pericardiocentesis needle insertion sites. The subxiphoid

and left sternocostal margins are the most commonly used sites (black dots).(Source: Medscape).

• Antiseptic solution Three-way stopcock scalpel

• Ultrasound machine with sterile probe

80 Essentials of Accident and Emergency Medicine

• Continuous cardiac or ECG monitoring

• Alligator clip connector for connection to V <sup>1</sup>

• Sterile drapes, gown, and mask

• Local anesthetic (e.g., lidocaine 1%)

• Pericardiocentesis kit

*7.1.4. Technique*

alternative.

There are various anatomical approaches for pericardiocentesis, as shown in the **Figure 7**, with subxiphoid approach and left parasternal margin being the most common sites (**Figure 8**).

In subxiphoid approach, mark the area between the xiphoid process and left sternocostal margin, ideally 1 cm inferolaterally to the xiphoid process on the left side. Clean the area using an antiseptic solution and insert the needle (spinal needle) at 30–45degrees, aiming toward the left shoulder, as shown in the picture.

If time permits, connect an alligator clip from the base of the spinal needle to the V<sup>1</sup> lead of an ECG machine, and use bedside ultrasound to visualize the needle tip in the pericardial as depicted in **Figure 9**.

Apply constant negative pressure on the syringe until a return of fluid or blood is visualized, cardiac pulsations are felt, or abrupt change in ECG waveform is noted (**Figure 10**).

Stabilize the needle and withdraw as much fluid as possible. If a catheter-over-the-needle has been used, then the needle can be removed and catheter can be stabilized to the chest wall, with a three-way stopcock attached to allow continuous drainage of pericardial fluid.

The needle may move closer to the myocardium, and an injury pattern may appear on the ECG, in which case the needle should be withdrawn slightly to avoid myocardial injury.

**Figure 8.** Needle insertion: Insert the spinal needle through the skin incision directed toward the left shoulder at a 45-degree angle to the abdominal wall and 45 degrees off the midline sagittal plane.

• Pneumothorax

• Hepatic injury

**7.3. Indications**

• Hemopericardium • Venous air embolism

• False-positive aspiration–intracardiac aspiration

• Reaccumulation of pericardial fluid defibrillation

Indications for defibrillation include the following:

• Pulseless ventricular tachycardia (VT)

• Cardiac arrest due to or resulting in VF

Contraindications include the following:

amine-induced arrhythmia • Multifocal atrial tachycardia

• Ventricular fibrillation (VF)

**7.4. Contraindications**

**7.5. Equipment needed**

brillators with monitors] • Paddle or adhesive patch • Conductive gel or paste

• ECG monitor with recorder

• Airway management equipment

• Emergency pacing equipment

• Oxygen equipment

to resume its normal cardiac cycle.

• False-negative aspiration—clotted blood in the pericardial cavity

"Defibrillation" or "unsynchronized cardioversion" is the transthoracic application of unsynchronized electric current during a cardiac cycle, causing the heart muscle to contract simultaneously and, thus, terminating the abnormal electrical rhythm. This enables the sinus node

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• Dysrhythmias due to enhanced automaticity, such as in digitalis toxicity and catechol-

• Defibrillators [automated external defibrillators (AEDs), semiautomated AEDs, standard defi-

**Figure 9.** Subxiphoid view of the heart demonstrating the needle tip within the pericardial space.

**Figure 10.** Needle insertion: slowly advance the spinal needle up to a depth of 5 cm while applying negative pressure on the syringe until a return of fluid is visualized.

#### **7.2. Complications**


"Defibrillation" or "unsynchronized cardioversion" is the transthoracic application of unsynchronized electric current during a cardiac cycle, causing the heart muscle to contract simultaneously and, thus, terminating the abnormal electrical rhythm. This enables the sinus node to resume its normal cardiac cycle.

#### **7.3. Indications**

Indications for defibrillation include the following:


#### **7.4. Contraindications**

Contraindications include the following:


#### **7.5. Equipment needed**


**7.2. Complications**

• Coronary artery puncture or aneurysm

the syringe until a return of fluid is visualized.

82 Essentials of Accident and Emergency Medicine

**Figure 10.** Needle insertion: slowly advance the spinal needle up to a depth of 5 cm while applying negative pressure on

**Figure 9.** Subxiphoid view of the heart demonstrating the needle tip within the pericardial space.

• Dry tap (failure to yield fluid)

• Dysrhythmias


#### **7.6. Technique**

Defibrillation is performed during a cardiac arrest while the CPR is going on simultaneously. So, it is important to carry out the CPR, along with proper administration of defibrillation technique for maximum benefit. Defibrillators can deliver either in monophasic (delivers a charge in only one direction) or biphasic (delivers a charge in one direction for half of the shock and in the electrically opposite direction for the second half) waveforms. Newer defibrillators deliver energy in biphasic waveforms as they tend to successfully terminate arrhythmias at lower energies than monophasic waveform defibrillators. The defibrillation process is done in three important steps, which are as follows:

*7.6.2. Defibrillator and Charging*

shock button to deliver the shock (**Figure 14**).

**Figure 12.** Defibrillation and cardioversion.

**Figure 11.** Paddle placement on the chest wall.

*7.6.3. Shock delivery*

Turn on the defibrillator, and turn the dial to defibrillation mode on the defibrillator (**Figure12**). Identify that the rhythm is a shockable rhythm. Select the energy of 360J for monophasic defibrillators or 120–200J for biphasic defibrillators, and select charge to start charging the

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As soon as the defibrillator is charged, which is indicated when the beep stops, press the

defibrillator, which is indicated by beginning of a beep sound (**Figure 13**).

#### *7.6.1. Paddle placement*

Apply conductive material to the entirety of the chest.

Conductive gel or paste is most commonly used, but waxy conductive pads are also available. Generous use of conductive gel on the underside and especially along the edges of the electrode paddles is essential, both to reduce transthoracic impedance and to prevent skin burns. Paste should be applied liberally but must not run onto the skin between the paddles, because the paste may divert current over the skin surface and away from the heart.

Paddle placement on the chest wall has two conventional positions:


In the anteroposterior position, which is preferred in patients with implantable devices, to avoid shunting current to the implantable device and damaging its system, a single paddle is placed to the right of the sternum, as above, and the other paddle is placed between the tip of the left scapula and the spine (**Figure 11**).

#### *7.6.2. Defibrillator and Charging*

Turn on the defibrillator, and turn the dial to defibrillation mode on the defibrillator (**Figure12**).

Identify that the rhythm is a shockable rhythm. Select the energy of 360J for monophasic defibrillators or 120–200J for biphasic defibrillators, and select charge to start charging the defibrillator, which is indicated by beginning of a beep sound (**Figure 13**).

#### *7.6.3. Shock delivery*

• Blood pressure cuff (automatic or manual)

three important steps, which are as follows:

• Anterolateral and anteroposterior.

the left scapula and the spine (**Figure 11**).

edge on the second or third intercostal space.

Apply conductive material to the entirety of the chest.

Paddle placement on the chest wall has two conventional positions:

• Code cart with advanced cardiovascular life support (ACLS) medications

Defibrillation is performed during a cardiac arrest while the CPR is going on simultaneously. So, it is important to carry out the CPR, along with proper administration of defibrillation technique for maximum benefit. Defibrillators can deliver either in monophasic (delivers a charge in only one direction) or biphasic (delivers a charge in one direction for half of the shock and in the electrically opposite direction for the second half) waveforms. Newer defibrillators deliver energy in biphasic waveforms as they tend to successfully terminate arrhythmias at lower energies than monophasic waveform defibrillators. The defibrillation process is done in

Conductive gel or paste is most commonly used, but waxy conductive pads are also available. Generous use of conductive gel on the underside and especially along the edges of the electrode paddles is essential, both to reduce transthoracic impedance and to prevent skin burns. Paste should be applied liberally but must not run onto the skin between the paddles, because the paste may divert current over the skin surface and away from the

• In the anterolateral position, a single paddle is placed on the left fourth or fifth intercostal space on the midaxillary line. The second paddle is placed just to the right of the sternal

In the anteroposterior position, which is preferred in patients with implantable devices, to avoid shunting current to the implantable device and damaging its system, a single paddle is placed to the right of the sternum, as above, and the other paddle is placed between the tip of

• Pulse recorder

• Suction device

**7.6. Technique**

• Intravenous access

• Sedation medications

*7.6.1. Paddle placement*

heart.

• Oxygen saturation monitor

84 Essentials of Accident and Emergency Medicine

As soon as the defibrillator is charged, which is indicated when the beep stops, press the shock button to deliver the shock (**Figure 14**).

**Figure 11.** Paddle placement on the chest wall.

**Figure 12.** Defibrillation and cardioversion.

• Ventricular fibrillation (VF) resulting from high amounts of electrical energy, especially in patients with digitalis toxicity, severe heart disease, or improper synchronization of the

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• Chest wall skin burns (most likely are due to improper technique or electrode placement

Transcutaneous pacing is a temporary means of pacing a patient's heart in an abnormally slow heart rate. It is accomplished by delivering pulses of electric current through the patient's

Indications for TCP can be grouped in bradyarrhythmias and tachyarrhythmias as follows:

• Symptomatic sinus node dysfunction (sinus arrest, tachybrady [sick sinus] syndrome,

• New left bundle-branch block (LBBB), right bundle-branch block (RBBB) with left axis

• Prophylaxis—cardiac catheterization, after open heart surgery, threatened bradycardia

deviation, bifascicular block, or alternating bundle-branch block • Trauma patient with hypotension and unresponsive bradycardia

• Supraventricular dysrhythmias (e.g., postoperative atrial flutter) • Ventricular dysrhythmias (monomorphic ventricular tachycardia)

chest, which stimulates the heart to contract in a minimally effective manner.

shock with the R wave

• Hypoxia due to excessive sedation

and inadequate conductive gel)

**8. Transcutaneous pacing**

**8.1. Indications**

*8.1.1. Bradyarrythmias*

sinus bradycardia)

*8.1.2. Tachyarrythmias*

• Second- and third-degree heart block • A-fib with slow ventricular response • Malfunction of implanted pacemaker

during drug trials for tachydysrhythmias

• Injuries to healthcare personnel (shock and burns)

• Thromboembolization

• Myocardial necrosis

**Figure 13.** Defibrillation and cardioversion.

**Figure 14.** Defibrillation and cardioversion.

Safety is a key concern in the performance of defibrillation. Any staff member acting as a ground for the electrical discharge can be seriously injured. The operator must announce "all clear" and give staff a chance to move away from the bed before discharging the paddles.

Care must be taken to clean up spills of saline or water, because they may create a conductive path to a staff person at the bedside.

After the shock is delivered, continue the CPR.

#### **7.7. Complications**

• Harmless arrhythmias, such as atrial, ventricular, and junctional premature beats (commonest)

