Pericardiocentesis

Quick Reference

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ACEM Exam Focus

What Examiners Expect

Primary Written/Viva:

• Applied anatomy of pericardial space and relations
• Physiology of cardiac tamponade (Beck's triad, pulsus paradoxus)
• Surface landmarks for subxiphoid approach
• Structures at risk during needle advancement

Fellowship Written:

• Indications and contraindications in ED context
• Differentiation: haemopericardium vs bloody tap
• ECG changes during procedure (injury pattern)
• Management of complications

Fellowship OSCE:

• Consent and preparation for emergency procedure
• Ultrasound-guided technique demonstration
• Recognition and management of complications
• Post-procedure care and disposition

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Key Points

1. Ultrasound-guided pericardiocentesis has 90-97% success rate compared to 50-80% for blind technique (PMID: 12628672, 23845463)

2. Beck's triad (hypotension, elevated JVP, muffled heart sounds) is present in only 10-40% of tamponade cases; absence does NOT exclude diagnosis (PMID: 17224524)

3. Subxiphoid approach is safest: avoids internal mammary and intercostal arteries, lowest pneumothorax risk, ultrasound visibility (PMID: 23845463)

4. Agitated saline test can differentiate bloody tap (bubbles in pericardium on echo) from haemopericardium (bubbles in cardiac chambers) (PMID: 8903661)

5. PEA arrest with tamponade is an absolute indication for immediate pericardiocentesis without imaging delay (ANZCOR Guideline 11.7.2)

6. Non-clotting aspirate suggests pericardial fluid (defibrinated); clotting blood suggests ventricular puncture or acute traumatic haemopericardium (PMID: 15302698)

7. Drain SLOWLY: Rapid removal greater than 1L can cause right ventricular dilatation, pulmonary oedema, and cardiac stunning (PMID: 11893776)

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Epidemiology

Incidence

• Pericardial effusion: 2-3% of echocardiograms (PMID: 15210946)
• Cardiac tamponade: 2 per 10,000 hospital admissions (PMID: 17224524)
• Emergency pericardiocentesis: 0.2-0.5 per 1,000 ED presentations with cardiac complaints (Australian data)

Aetiology of Pericardial Effusion

Australian/NZ Context

• Remote trauma: Delayed presentation with tamponade physiology from missed cardiac injury
• Indigenous populations: Higher rates of rheumatic heart disease, TB pericarditis (PMID: 29141444)
• RFDS retrieval: Limited echocardiography, reliance on clinical diagnosis

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Pathophysiology

Physiology of Cardiac Tamponade

Pericardial Compliance Curve

Normal pericardial pressure: 0-5 mmHg
Volume accommodation:
- Acute: 100-200 mL → tamponade (stiff pericardium)
- Chronic: Up to 2L tolerated (pericardium stretches over weeks)

Tamponade physiology:
1. Pericardial pressure exceeds right atrial pressure
2. Diastolic filling impaired (right heart first)
3. Stroke volume ↓ → CO ↓ → BP ↓
4. Compensatory tachycardia and vasoconstriction
5. Eventual cardiovascular collapse

Pulsus Paradoxus

• Exaggeration of normal physiological phenomenon
• Normal: SBP drops below 10 mmHg during inspiration
• Tamponade: SBP drops greater than 10 mmHg (often 15-30 mmHg)
• Mechanism: Increased venous return during inspiration → septal shift → reduced LV filling → reduced SBP
• Sensitivity: 80-90% for tamponade (PMID: 17224524)
• Absent in: Atrial septal defect, severe aortic regurgitation, regional tamponade

(PMID: 17224524, 11893776)

Beck's Triad

Complete triad: Present in only 10-40% of cases (PMID: 17224524)

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Clinical Presentation

Symptoms

• Dyspnoea: 85-90% (most common)
• Chest pain: 30-50% (pleuritic, positional)
• Palpitations: 20-30%
• Syncope/presyncope: 10-20% (advanced tamponade)
• Anxiety: 60-70% ("sense of impending doom")

(PMID: 15210946)

Signs

ECG Findings

• Low voltage QRS: below 5mm in limb leads, below 10mm in chest leads (60-70%)
• Electrical alternans: Beat-to-beat variation in QRS amplitude (20-30%, specific for tamponade) (PMID: 15302698)
• Sinus tachycardia: 80-90%
• PR depression: Atrial injury pattern (30-40%)
• ST elevation: Diffuse concave ST elevation in pericarditis

(PMID: 15302698)

Echocardiographic Features

Diagnostic:

• Pericardial effusion greater than 10mm in diastole
• Right atrial collapse in systole: 50-60% sensitive, 85% specific (PMID: 12628672)
• Right ventricular diastolic collapse: 90% sensitive, 65% specific (PMID: 12628672)
• Plethoric IVC (greater than 2cm, below 50% inspiratory collapse)
• Respiratory variation in tricuspid inflow greater than 40%, mitral inflow greater than 25%

Grading Effusion Size:

(PMID: 12628672, 23845463)

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Indications

Absolute Indications

Relative Indications

1. Diagnostic sampling:

   • Suspected malignant effusion
   • Suspected infectious pericarditis (TB, bacterial)
   • Effusion of unknown aetiology

2. Moderate effusion with symptoms:

   • Persistent dyspnoea
   • Chest pain despite medical therapy
   • Pericarditis refractory to NSAIDs/colchicine

3. Recurrent effusion:

   • Consider pericardial window if recurrent after 2+ drainage procedures

(PMID: 23845463, 15210946)

When to Consider in ED

• Blunt/penetrating chest trauma with pericardial effusion on FAST
• PEA arrest with undifferentiated cause (rule out tamponade)
• Post-cardiac intervention (PCI, pacemaker) with new effusion
• Malignancy with new dyspnoea and hypotension
• Renal failure on dialysis with unexplained haemodynamic instability

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Contraindications

Absolute

Relative Contraindications

(PMID: 23845463, 12628672)

Risk-Benefit Considerations

Proceed despite relative contraindications when:

• PEA arrest or peri-arrest
• Refractory cardiogenic/obstructive shock
• No surgical backup available (remote/rural)
• Transfer would be fatal

Defer to cardiothoracic surgery when:

• Stable patient with loculated effusion
• Post-surgical tamponade
• Suspected aortic dissection
• Purulent pericarditis

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Anatomy

Pericardial Space

Structure:

• Fibrous pericardium: Tough outer layer, fused to diaphragm inferiorly
• Parietal pericardium: Serous membrane lining fibrous pericardium
• Visceral pericardium: Epicardium adherent to myocardium
• Pericardial cavity: Potential space, normally 15-50 mL serous fluid

Relations:

• Anterior: Sternum, costal cartilages 4-7, thymus remnant, mediastinal pleura
• Posterior: Oesophagus, descending aorta, vertebrae T5-T8
• Inferior: Diaphragm (central tendon)
• Superior: Great vessels (aorta, pulmonary artery, SVC)
• Lateral: Phrenic nerves, mediastinal pleura, lungs

(PMID: 15210946)

Surface Landmarks for Subxiphoid Approach

Deep Anatomy

Layers encountered (subxiphoid approach):

1. Skin
2. Subcutaneous fat
3. Linea alba (minimal)
4. Diaphragm (muscular portion, left of midline)
5. Pericardial fat pad
6. Parietal pericardium (resistance "pop")
7. Pericardial cavity (fluid return)

Key relationships:

• Heart positioned: Left of midline, apex at 5th intercostal space mid-clavicular line
• Right ventricle: Most anterior chamber, at risk of puncture
• Liver: Inferior to pericardium, avoid by entering LEFT of midline
• Coronary arteries: Right coronary in AV groove, left anterior descending in interventricular groove

(PMID: 23845463)

Anatomical Diagram

LATERAL VIEW (Subxiphoid Approach):

        Left shoulder (aim here)
              ↑
              |
          30-45° angle
            /
           /
    Xiphoid ●───→ Entry: 1-2cm inferior, 1cm LEFT
          /
    Diaphragm
        |
  Pericardium (6-8cm depth)
        |
    Pericardial cavity
        |
      Heart
        └── RV (most anterior, at risk)


CROSS-SECTION (Looking from feet toward head):

         Sternum
            |
    ┌───────┴───────┐
    │   RV    LV    │  Heart
    └───────────────┘
         ↓ Entry point
    Pericardial fluid
            ↓
    1-2cm inferior to xiphoid
    1cm LEFT of midline

Danger Zones

Anatomical Variants

Common variants affecting procedure:

1. Xiphoid calcification: Elderly patients; palpate carefully, may need to go more inferior
2. Pericardial adhesions: Post-cardiac surgery, recurrent pericarditis; consider surgical approach
3. Prominent pericardial fat pad: Obese patients; may mistake fat for effusion on echo
4. Dextrocardia: Reverse approach, enter RIGHT of midline
5. Hepatomegaly: Increases risk of liver injury; use ultrasound guidance

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Equipment

Essential Equipment

Optional Equipment

Ultrasound Equipment

Probe selection:

• Phased array (cardiac): 2-5 MHz, small footprint, optimal for cardiac imaging
• Curvilinear: 3-5 MHz, alternative if phased array unavailable
• Linear: NOT suitable (insufficient depth)

Views required:

1. Subxiphoid view: Visualize effusion, needle trajectory
2. Apical 4-chamber: Confirm effusion, assess ventricular function
3. Parasternal long axis: Confirm effusion, measure depth

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Preparation

Patient Preparation

1. Consent (if conscious):

   • Explain indication: "Fluid around your heart is preventing it from beating effectively"
   • Explain procedure: "We need to drain this fluid with a needle"
   • Explain risks: "Small risk of bleeding, infection, injury to heart or lung"
   • Emergency situation: Document if consent not possible

2. Positioning:

   • Supine: Head of bed 30-45° elevation (improves venous return, pools fluid inferiorly)
   • Alternative: Sitting upright if respiratory distress severe
   • Arms at sides or across chest

3. Monitoring:

   • Continuous ECG (5-lead, ST-segment monitoring)
   • Non-invasive BP (every 1-2 minutes)
   • SpO₂
   • End-tidal CO₂ if intubated

4. IV access:

   • Large-bore IV x 2 (16G or 18G)
   • Fluid resuscitation if hypotensive
   • Vasopressors AFTER drainage (may worsen tamponade by increasing afterload) (PMID: 11893776)

5. Pre-procedure checklist:

   • Consent obtained/documented
   • Echo confirms effusion greater than 10mm
   • Coagulation checked (if time permits)
   • Resuscitation equipment ready
   • Cardiothoracic surgery notified (if available)

Operator Preparation

1. Standard precautions:

   • Sterile gown
   • Sterile gloves
   • Mask with eye protection
   • Head cover

2. Hand hygiene:

   • Surgical scrub (chlorhexidine or povidone-iodine)
   • 2-minute scrub

3. Equipment check:

   • All equipment opened and checked
   • Syringes flushed
   • Guidewire free-moving
   • Catheter side holes patent

4. Assistance arranged:

   • Nurse to assist with equipment
   • Second operator for ultrasound (if available)
   • Resuscitation team on standby

5. Backup plan identified:

   • Surgical airway equipment ready
   • Thoracotomy tray available (if traumatic tamponade)
   • Cardiothoracic surgery contact number

Site Preparation

1. Sterile technique: Full aseptic technique

   • Large field (nipples to umbilicus, laterally to mid-axillary lines)
   • Sterile ultrasound gel in sterile container

2. Skin preparation:

   • Chlorhexidine 2% in 70% alcohol
   • Allow to dry (30-60 seconds)
   • Concentric circles from entry point outward

3. Draping:

   • Fenestrated drape over entry site
   • Secondary drapes to create large sterile field
   • Sterile probe cover for ultrasound

Positioning

• Patient position: Supine, head of bed 30-45° elevation
• Operator position: Stand on patient's RIGHT side (for right-handed operator)
• Assistant position: Stand on patient's LEFT side, operates ultrasound

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Procedure Steps: Ultrasound-Guided Seldinger Technique

Pre-Procedure Ultrasound Assessment

Confirm effusion:

1. Subxiphoid view: Identify pericardial effusion (echo-free space around heart)
2. Measure depth: Distance from skin to pericardium (typically 4-8 cm)
3. Identify target: Largest, most accessible pocket (usually inferior to RV, anterior to liver)
4. Measure effusion size: Should be greater than 10mm in diastole for safety

Identify anatomy:

• Visualize RV, RA, pericardium, diaphragm, liver
• Trace needle trajectory mentally
• Avoid chambers, aim for inferior-anterior pericardial space

(PMID: 12628672, 23845463)

Step 1: Local Anaesthesia

Technique:

1. Identify entry point: 1-2 cm inferior to xiphoid, 1 cm LEFT of midline
2. Inject 1% lidocaine:
   • Raise skin wheal (1-2 mL)
   • Infiltrate subcutaneous tissue (3-5 mL)
   • Advance at 30-45° angle toward left shoulder
   • Aspirate before each injection
   • Inject along intended needle path (5-10 mL total)
   • Infiltrate to pericardium if time permits

Key point: Anesthetize generously; patient movement during procedure is dangerous

Common error: Inadequate anaesthesia of peritoneum and pericardium (causes pain during advancement)

Step 2: Needle Advancement (Ultrasound-Guided)

Attach alligator clip (optional but recommended):

• Connect ECG V lead to metal hub of spinal needle
• Monitor ST-segment elevation (indicates myocardial contact)
• ST elevation: Withdraw needle until ST normalizes (PMID: 15302698)

Advance needle:

1. Hold syringe with dominant hand, attach to spinal needle
2. Insert at entry point, 30-45° angle toward LEFT shoulder
3. Advance SLOWLY (1-2 mm increments)
4. Continuous gentle aspiration during advancement
5. Visualize needle tip with ultrasound (hyperechoic line)

Depth markers:

• Skin to pericardium: Usually 6-8 cm
• "Pop" sensation: Passing through pericardium (not always felt)
• Sudden fluid return: Entry into pericardial space

Key point: Advance ONLY during aspiration; stop immediately if fluid returns

Common error: Advancing too far (ventricular puncture), advancing too fast (loss of control)

(PMID: 23845463)

Step 3: Confirm Pericardial Fluid

Free-flowing non-clotting fluid:

• Pericardial fluid is defibrinated (does NOT clot in syringe)
• Blood from ventricular puncture CLOTS within 5-10 minutes
• Aspirate 5-10 mL, observe in syringe for 5 minutes

Agitated saline test (if uncertain):

1. Inject 5-10 mL agitated saline (shake syringe with 2-3 mL air)
2. Visualize with ultrasound:
   • Pericardial space: Bubbles appear in pericardium (correct position)
   • Cardiac chamber: Bubbles appear in RV/RA (ventricular puncture - withdraw needle)

(PMID: 8903661)

Haemodynamic improvement:

• Removal of even 50-100 mL can significantly improve CO
• Monitor BP, heart rate during aspiration

Step 4: Seldinger Technique - Guidewire Insertion

Once pericardial space confirmed:

1. Stabilize needle hub with non-dominant hand
2. Disconnect syringe with dominant hand
3. Insert J-tip guidewire through needle
4. Advance wire 10-15 cm into pericardial space
5. Monitor ECG: Arrhythmias indicate wire touching myocardium - withdraw 2-3 cm

Key point: NEVER advance wire against resistance (risk of perforation)

Common error: Losing needle position during wire insertion (hold hub firmly)

(PMID: 23845463)

Step 5: Catheter Insertion

1. Remove needle: Withdraw over guidewire (keep wire in place with non-dominant hand)
2. Skin nick: Small incision at wire entry site with 11-blade scalpel (facilitates dilator/catheter passage)
3. Dilate tract: Advance dilator over wire with twisting motion (7-8 Fr)
4. Remove dilator: Withdraw over wire
5. Insert pigtail catheter: Advance 6-8 Fr pigtail catheter over wire
6. Remove wire: Withdraw guidewire, leaving catheter in pericardium
7. Confirm position: Aspirate freely through catheter, visualize with ultrasound

Key point: Maintain wire control at all times; never let go of proximal wire end

Common error: Advancing catheter without adequate dilation (kinking, failure to advance)

Step 6: Drainage

Aspiration technique:

1. Attach three-way stopcock and 60 mL syringe to catheter
2. Aspirate 50 mL aliquots
3. Monitor haemodynamics continuously
4. Drain slowly: No more than 1L in first hour (risk of RV dilatation, pulmonary oedema) (PMID: 11893776)

Send samples:

Fluid characteristics:

(PMID: 15210946)

Step 7: Securing Catheter

1. Suture to skin: 2-0 silk, secure pigtail to chest wall
2. Sterile dressing: Transparent dressing allows monitoring
3. Connect to drainage bag: Closed sterile system, gravity drainage
4. Secure tubing: Prevent accidental dislodgement

Confirmation of Success

(PMID: 12628672)

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Alternative Approach: Apical (Left 5th/6th Intercostal Space)

When to Use

• Subxiphoid approach failed or inaccessible
• Loculated anterior-lateral effusion
• Large left-sided effusion on echo

Technique

• Entry point: 5th or 6th intercostal space, mid-clavicular line (cardiac apex)
• Angle: Perpendicular to skin, directed medially toward right shoulder
• Depth: 3-5 cm (shorter than subxiphoid)

Advantages

• Shorter distance to pericardium
• Useful for loculated lateral effusions

Disadvantages

• Higher risk of pneumothorax (10-15%) due to pleura proximity
• Higher risk of coronary laceration (LAD nearby)
• Contraindicated if patient on positive pressure ventilation (pleural injury risk)

(PMID: 17224524)

ACEM Recommendation: Subxiphoid approach is preferred; reserve apical for cases where subxiphoid not feasible and surgical backup unavailable

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Paediatric Considerations

Age-Specific Modifications

Equipment Sizing

Paediatric pericardiocentesis kit:

• Needle: 20-22G, 5-7 cm length
• Guidewire: 0.018" or 0.025" (smaller than adult)
• Catheter: 4-5 Fr pigtail

Technique Modifications

1. Depth: Much shallower than adults (2-6 cm depending on age)
2. Angle: May need steeper angle (45-60°) due to more horizontal heart position
3. Volume: Drain smaller volumes (10-20 mL/kg max in first hour)
4. Sedation: Consider procedural sedation (ketamine 1-2 mg/kg IV) if not in extremis

Common paediatric aetiologies:

• Post-cardiac surgery (most common)
• Kawasaki disease
• Viral pericarditis
• Malignancy (leukaemia, lymphoma)

(PMID: 23845463)

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Complications

Immediate Complications

Delayed Complications

Complication Prevention

Strategies to minimize complications:

1. Use ultrasound guidance: Reduces complications by 50% (PMID: 12628672)
2. Seldinger technique: Allows smaller initial needle, safer than large-bore catheter insertion
3. Subxiphoid approach: Avoids pleura, lower pneumothorax risk
4. ECG monitoring: ST elevation warns of myocardial contact
5. Drain slowly: Prevents RV dilatation and pulmonary oedema
6. Maintain sterility: Reduces infection risk
7. Experienced operator: Complication rate inversely related to operator experience

(PMID: 23845463)

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Troubleshooting

Rescue Techniques

If pericardiocentesis fails or complications occur:

1. Emergency thoracotomy (traumatic tamponade):

   • Left anterolateral thoracotomy (5th intercostal space)
   • Pericardiotomy anterior to phrenic nerve
   • Manual cardiac massage
   • Control bleeding source

2. Surgical pericardial window:

   • Subxiphoid or left anterior thoracotomy approach
   • Creates permanent drainage pathway
   • Indicated for recurrent effusions

3. Supportive measures while awaiting surgery:

   • Fluid resuscitation (expand intravascular volume)
   • Avoid vasopressors (increase myocardial oxygen demand)
   • Inotropes (dobutamine 5-10 mcg/kg/min) if available
   • Positive pressure ventilation AFTER drainage only (increases intrathoracic pressure → worsens tamponade)

(PMID: 11893776)

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Post-Procedure Care

Immediate Care

1. Post-drainage echo:

   • Confirm effusion reduced/resolved
   • Assess for re-accumulation
   • Check for new haemopericardium (complication)

2. Chest X-ray:

   • Confirm catheter position
   • Exclude pneumothorax
   • Exclude new pleural effusion

3. 12-lead ECG:

   • Assess for injury pattern (ST elevation → myocardial injury)
   • Monitor for arrhythmias

4. Send fluid for analysis:

   • Culture (bacterial, fungal, AFB)
   • Cytology (malignancy)
   • Biochemistry (protein, LDH, glucose, ADA)
   • Cell count and differential

5. Documentation:

   • Indication
   • Consent process
   • Technique used (subxiphoid vs apical, ultrasound-guided)
   • Volume drained, fluid appearance
   • Complications
   • Post-procedure echo findings

Monitoring

Catheter Management

Indications to LEAVE catheter in situ:

• Large initial drainage (greater than 500 mL)
• Continued drainage greater than 50 mL/hr
• High risk of re-accumulation (malignancy, uraemia, purulent)

Indications to REMOVE catheter:

• Drainage below 25 mL/24 hours for 2 consecutive days
• No effusion on echo
• Catheter complications (infection, malposition)

Duration:

• Typically 24-72 hours
• May be longer for malignant or purulent effusions

(PMID: 15210946)

Disposition

ICU admission:

• Post-arrest tamponade
• Haemodynamically unstable despite drainage
• Complications (ventricular perforation, coronary laceration)
• Continued high drainage output (greater than 100 mL/hr)

Monitored bed:

• Stable post-drainage
• Catheter in situ
• Risk of re-accumulation

Transfer to tertiary centre:

• Requires cardiothoracic surgery
• Recurrent effusion requiring pericardial window
• Purulent pericarditis
• Constrictive pericarditis

Follow-Up

Outpatient:

• Repeat echo in 1 week to assess for re-accumulation
• Treat underlying cause (malignancy, uraemia, infection)
• Cardiology review for recurrent/chronic effusions

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Special Populations

Traumatic Tamponade

Key differences from medical tamponade:

• Acute haemopericardium: Clotting blood, difficult to drain percutaneously
• Cardiac laceration: Requires surgical repair, pericardiocentesis is TEMPORARY measure
• Indication for thoracotomy: Penetrating trauma with arrest/peri-arrest

Management:

1. Activate trauma team and cardiothoracic surgery immediately
2. Pericardiocentesis: Temporizing measure only
   • May drain enough to restore output for transport to OR
   • Expect re-accumulation
3. Emergency thoracotomy if:
   • Arrest in ED
   • Refractory shock despite pericardiocentesis
   • Penetrating thoracic trauma with tamponade

(PMID: 17224524)

Malignant Effusion

Characteristics:

• Often bloody (Hct greater than 5%)
• High recurrence rate (40-70%)
• Associated with advanced malignancy (poor prognosis)

Management:

1. Diagnostic pericardiocentesis (cytology)
2. Consider pericardial window for recurrent effusions
3. Sclerosing agents (tetracycline, bleomycin) via catheter (reduce recurrence)
4. Palliative care involvement for end-stage disease

(PMID: 15210946)

Uraemic Effusion

Characteristics:

• Dialysis-dependent renal failure
• May not respond to intensified dialysis
• Often recurrent

Management:

1. Drain acutely if tamponade
2. Intensify dialysis (daily if needed)
3. NSAIDs/colchicine for pericarditis
4. Pericardial window if recurrent despite dialysis

(PMID: 9040898)

Post-Cardiac Surgery

Characteristics:

• Often loculated (organized clot)
• Difficult to drain percutaneously
• May have regional tamponade (RA or RV selective compression)

Management:

1. Surgical re-exploration preferred (organized clot, loculations)
2. Percutaneous drainage may temporize if surgery delayed
3. High recurrence rate

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Remote/Rural ED Considerations

Limited Ultrasound Access

If echo unavailable:

• Clinical diagnosis: Beck's triad, pulsus paradoxus, electrical alternans on ECG
• Blind pericardiocentesis: Higher complication rate (50% success vs 90-97% with ultrasound)
• Indication: PEA arrest or peri-arrest only (risk-benefit favors attempt)
• RFDS retrieval: Consider early activation for ultrasound-capable team

Telemedicine Support

Utilize RFDS/retrieval teams:

• Video guidance for procedure
• Ultrasound image transmission
• Decision support for disposition

Transfer Decisions

Transfer indications:

• Recurrent effusion (requires pericardial window)
• Loculated effusion (surgical drainage)
• Post-procedure complications
• Underlying aetiology requiring specialist care (malignancy, TB)

Temporizing measures during transfer:

• Leave catheter in situ on drainage
• IV access and fluid resuscitation
• Continuous monitoring
• Avoid positive pressure ventilation if possible (worsens tamponade)

Equipment Availability

Minimum required:

• 18G spinal needle or long IV catheter
• Syringe for aspiration
• Sterile technique equipment
• If Seldinger kit unavailable: Aspiration only (no catheter left in situ)

(Australian College of Rural and Remote Medicine recommendations)

---

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Communities

Epidemiology:

• Higher rates of rheumatic heart disease → pericarditis, effusion (PMID: 29141444)
• Higher rates of tuberculosis → TB pericarditis (PMID: 26040576)
• Remote living: Delayed presentations with advanced tamponade

Cultural considerations:

1. Family involvement: Extended family should be included in consent and care
2. Gender: Consider gender of proceduralist (request for same-sex clinician)
3. Communication: Use interpreter services, avoid medical jargon
4. Death and dying: Cultural protocols if prognosis poor (senior cultural advisor, traditional healing)

Access barriers:

• Delayed presentation due to distance, cost, cultural factors
• Limited availability of echocardiography in remote communities
• RFDS retrieval may be delayed by weather, distance

Māori Health (New Zealand)

Cultural competence:

1. Whānau (family) involvement: Whānau-centred care, involve extended family in decisions
2. Tikanga (cultural protocols): Respect for Māori customs, karakia (prayer) if requested
3. Manaakitanga (hospitality): Welcoming environment, cultural safety
4. Te reo Māori: Use Māori language where appropriate, interpreter services

Health disparities:

• Higher cardiovascular disease burden
• Higher rates of rheumatic fever → pericarditis
• Socioeconomic barriers to specialist care

(PMID: 29141444)

---

ACEM Exam Practice

Viva Questions

Viva Scenario 1: Emergency Pericardiocentesis

Stem: "A 55-year-old man presents with dyspnoea and hypotension. He has a history of metastatic lung cancer. On examination, BP 80/60, HR 130, JVP elevated, heart sounds muffled. ECG shows low voltage QRS and electrical alternans. You perform a bedside echo which shows a large pericardial effusion with right ventricular diastolic collapse."

Q1: What is your diagnosis and immediate management priority?

Model Answer:

• Diagnosis: Cardiac tamponade (most likely malignant pericardial effusion)
• Evidence: Beck's triad (hypotension, elevated JVP, muffled heart sounds), electrical alternans (highly specific for tamponade), echo shows effusion with RV collapse (diagnostic of tamponade physiology)
• Immediate priority: Emergency pericardiocentesis
  • "Temporizing measures: IV fluid bolus 500-1000 mL (expand intravascular volume), avoid positive pressure ventilation"
  • "Call for help: Senior ED, cardiology, cardiothoracic surgery"
  • "Prepare for procedure: Gather equipment, consent, position patient"

Q2: Describe your technique for pericardiocentesis.

Model Answer:

• Approach: Ultrasound-guided subxiphoid Seldinger technique
• Steps:
  1. Pre-procedure echo: Confirm effusion, measure depth, identify target
  2. Preparation: Sterile technique, local anaesthetic, monitoring
  3. Needle insertion: 18G spinal needle, 1-2 cm inferior and left of xiphoid, 30-45° angle toward left shoulder
  4. Ultrasound guidance: Visualize needle advancement, stop when fluid returns
  5. Confirm pericardial space: Non-clotting fluid, agitated saline test if uncertain
  6. Seldinger technique: Guidewire insertion, dilator, pigtail catheter (6-8 Fr)
  7. Drain slowly: 50 mL aliquots, max 1L in first hour
  8. Secure catheter: Suture to skin, connect to drainage bag
  9. Post-procedure: Echo, CXR, send fluid for culture/cytology

Q3: What complications can occur and how do you recognise them?

Model Answer:

• Ventricular perforation (1-2%):
  • "Recognition: Haemodynamic collapse, clotting blood aspirated, ST elevation on ECG"
  • "Management: Withdraw needle, fluid resuscitate, activate cardiothoracic surgery, may require thoracotomy"
• Coronary laceration (1-3%):
  • "Recognition: Chest pain, ST elevation, cardiogenic shock, haemopericardium on echo"
  • "Management: Immediate surgical consultation, may require CABG"
• Arrhythmias (5-15%):
  • "Recognition: VT/VF (wire touching myocardium), bradycardia (vagal)"
  • "Management: Withdraw wire/needle, treat per ACLS, usually transient"
• Pneumothorax (1% subxiphoid, 10-15% apical):
  • "Recognition: Respiratory distress, absent breath sounds, CXR"
  • "Management: Needle decompression if tension, chest drain"

Q4: This patient re-accumulates 500 mL over 24 hours. What is your management?

Model Answer:

• Re-accumulation common with malignant effusions (40-70%)
• Options:
  1. Re-drainage: Percutaneous if haemodynamically stable
  2. Pericardial window: Surgical (subxiphoid or thoracoscopic), creates permanent drainage, preferred for recurrent malignant effusions
  3. Sclerosing agents: Tetracycline or bleomycin via catheter, reduces recurrence
  4. Palliative care: Involvement for end-stage malignancy, goals of care discussion
• Disposition: Cardiothoracic surgery referral for pericardial window

Viva Scenario 2: Traumatic Tamponade

Stem: "A 28-year-old man is brought to ED after a stab wound to the left chest. He is GCS 14, BP 70/50, HR 140, RR 30, SpO₂ 92% on high-flow oxygen. FAST shows pericardial fluid. He has a 3 cm stab wound at the 4th intercostal space, 2 cm left of the sternum."

Q1: What is your diagnosis and management approach?

Model Answer:

• Diagnosis: Penetrating cardiac injury with cardiac tamponade
• Management approach:
  1. Immediate resuscitation:
     • Activate trauma team and cardiothoracic surgery
     • IV access x 2 (large bore)
     • Fluid resuscitation (permissive hypotension SBP 80-90)
     • Blood products (MTP if available)
     • Avoid intubation if possible (positive pressure worsens tamponade)
  2. Pericardiocentesis: Temporizing measure only
     • May drain enough to restore output for transport to OR
     • Expect re-accumulation (cardiac laceration requires surgical repair)
  3. Definitive management: Emergency thoracotomy or sternotomy
     • Surgical repair of cardiac laceration
     • Control bleeding

Q2: The patient arrests in the ED. What is your next step?

Model Answer:

• Emergency resuscitative thoracotomy (ANZCOR Guideline 11.7.2)
• Indication: Penetrating thoracic trauma with witnessed arrest in ED or within 10 minutes of pre-hospital arrest
• Technique:
  1. Left anterolateral thoracotomy (5th intercostal space)
  2. Pericardiotomy anterior to phrenic nerve
  3. Evacuate clot, identify bleeding source
  4. Digital occlusion of cardiac laceration or staple/suture if equipment available
  5. Manual cardiac massage (internal)
  6. Cross-clamp descending aorta if needed
  7. Transport to OR for definitive repair

Q3: What is the difference between traumatic and medical tamponade?

Model Answer:

Q4: What are the indications for resuscitative thoracotomy in penetrating trauma?

Model Answer (per ANZCOR Guideline 11.7.2):

• Penetrating thoracic trauma:
  • Arrest witnessed in ED, OR
  • Arrest within 10 minutes of arrival (pre-hospital arrest)
  • PEA with suspected tamponade
• Penetrating abdominal trauma:
  • Arrest witnessed in ED with suspected exsanguination
• NOT indicated:
  • Blunt trauma arrest (survival below 2%)
  • Prolonged pre-hospital CPR (greater than 15 minutes)
  • Asystole

Viva Scenario 3: Differential Diagnosis

Stem: "You aspirate 60 mL of blood during pericardiocentesis. The blood clots in the syringe within 5 minutes."

Q1: What does clotting blood indicate and what is your next step?

Model Answer:

• Clotting blood indicates:
  • "Ventricular puncture (most likely): Fresh blood from cardiac chamber"
  • "OR Acute traumatic haemopericardium: Recent bleeding into pericardium"
• Differentiation:
  • "Pericardial fluid: Defibrinated (does NOT clot) - has been in pericardium long enough for fibrinolytic enzymes to defibrinate"
  • "Ventricular puncture: Clots within 5-10 minutes"
• Next step:
  1. Withdraw needle 1-2 cm
  2. Redirect more superficially (away from myocardium)
  3. Consider agitated saline test to confirm location
  4. Monitor ECG for ST elevation (indicates myocardial contact)
  5. If persistent, abort procedure and reassess with ultrasound

Q2: Describe the agitated saline test.

Model Answer:

• Purpose: Differentiate pericardial space from cardiac chamber
• Technique:
  1. Inject 5-10 mL agitated saline (shake syringe with 2-3 mL air to create microbubbles)
  2. Visualize with echocardiography
• Interpretation:
  • "Bubbles in pericardium: Needle in pericardial space (correct position)"
  • "Bubbles in RV/RA: Needle in cardiac chamber (ventricular puncture - reposition)"
• Evidence: PMID: 8903661

Q3: What is the significance of the haematocrit of pericardial fluid?

Model Answer:

• Bloody pericardial effusion: Common in malignancy, trauma, iatrogenic
• Haematocrit comparison:
  • "Hct pericardial fluid / Hct blood < 0.5: Chronic bloody effusion (diluted by serous fluid)"
  • "Hct pericardial fluid / Hct blood > 0.5: Acute haemopericardium or ventricular puncture"
• Clinical correlation:
  • "Traumatic haemopericardium: Hct ratio ~1 (pure blood)"
  • "Malignant effusion: Hct ratio 0.2-0.5 (mixed)"
• Evidence: PMID: 15210946

Viva Scenario 4: Remote ED Management

Stem: "You are working in a remote ED in the Northern Territory. A 45-year-old Aboriginal man presents with dyspnoea and hypotension. You suspect cardiac tamponade but do not have ultrasound or pericardiocentesis kit available. The nearest tertiary centre is 600 km away, and RFDS retrieval will take 3 hours."

Q1: How do you make the diagnosis of tamponade without ultrasound?

Model Answer:

• Clinical diagnosis:
  1. Beck's triad: Hypotension, elevated JVP, muffled heart sounds (only 10-40% have all three)
  2. Pulsus paradoxus: Drop in SBP greater than 10 mmHg with inspiration (80-90% sensitive)
     • Measure: Inflate BP cuff, deflate slowly, note first Korotkoff sound (during expiration), continue deflating until Korotkoff sounds heard throughout respiratory cycle, difference greater than 10 mmHg = positive
  3. ECG findings:
     • Low voltage QRS (below 5mm limb leads, below 10mm chest leads)
     • Electrical alternans (beat-to-beat variation in QRS amplitude - highly specific)
     • Sinus tachycardia
• Supportive findings:
  • "Risk factors: Known malignancy, uraemia, recent cardiac procedure"
  • Narrow pulse pressure (below 30 mmHg)
  • Tachypnoea, orthopnoea

Q2: You do not have a pericardiocentesis kit. What alternatives do you have?

Model Answer:

• Improvised equipment:
  1. 18G or 16G IV catheter (instead of spinal needle)
     • Shorter length (limits depth control)
     • Remove stylet once fluid returns, advance catheter over needle
  2. 20 mL syringe for aspiration
  3. Three-way stopcock to allow repeated aspiration
  4. Sterile technique: Chlorhexidine, sterile gloves, drape
• Aspiration only (no Seldinger, no catheter left in situ):
  • Aspirate what you can to temporize
  • Expect re-accumulation
  • URGENT RFDS retrieval for definitive management
• Telemedicine support:
  • Video call with retrieval team or emergency physician at tertiary centre
  • Guidance for procedure

Q3: What are the cultural considerations in obtaining consent for this procedure?

Model Answer:

• Aboriginal and Torres Strait Islander cultural safety:
  1. Family involvement: Speak with patient AND family members (extended family, elders)
  2. Interpreter: Use Aboriginal interpreter service if language barrier
  3. Explanation: Avoid medical jargon, use simple language, visual aids
  4. Time: Allow time for discussion, questions, family consensus
  5. Gender: Offer same-sex clinician if requested (cultural modesty)
  6. Traditional healing: Respect for traditional medicine, involve Aboriginal liaison officer
• Emergency context:
  • If life-threatening and patient unable to consent, document emergency situation
  • Involve family as soon as possible after procedure
  • Debrief with patient and family post-procedure

Q4: The patient improves after aspiration of 200 mL. What is your disposition plan?

Model Answer:

• Temporizing successful: Patient stabilized
• RFDS retrieval: Urgent (within hours)
  • "Clinical details: Working diagnosis, volume aspirated, current haemodynamics"
  • "Equipment: Request echo-capable team, pericardiocentesis kit"
  • "Transfer plan: Leave IV access x 2, fluid bolus available, continuous monitoring"
• Ongoing care pre-retrieval:
  • "Monitor for re-accumulation: Vital signs Q15min, clinical signs of tamponade"
  • "Fluid resuscitation: Maintain preload"
  • "Avoid: Positive pressure ventilation if possible, vasopressors (may worsen tamponade)"
  • Prepare for repeat aspiration if deteriorates
• Tertiary centre management:
  • Echo-guided pericardiocentesis with catheter placement
  • Investigate underlying cause
  • Cardiology/cardiothoracic surgery involvement

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OSCE Scenarios

OSCE Station 1: Consent for Emergency Pericardiocentesis

Setting: ED resuscitation bay

Time: 11 minutes

Scenario: You are the emergency registrar. A 60-year-old woman has presented with dyspnoea and hypotension. Bedside echo shows a large pericardial effusion with tamponade physiology. You need to perform emergency pericardiocentesis. The patient is conscious and able to consent. Obtain consent for the procedure.

Actor Briefing: You are frightened and do not understand what is happening. You have difficulty with medical terminology. You are worried about risks and want to know if there are alternatives.

Candidate Instructions:

You are the emergency registrar. A 60-year-old woman has presented with dyspnoea and hypotension. Bedside echo shows a large pericardial effusion causing cardiac tamponade. You need to perform emergency pericardiocentesis. Obtain informed consent from the patient.

Marking Criteria:

Pass mark: 7/11

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OSCE Station 2: Procedural Skills - Pericardiocentesis

Setting: Simulated resuscitation bay with mannequin

Time: 11 minutes

Scenario: You are the emergency registrar. You have a patient with cardiac tamponade requiring emergency pericardiocentesis. Perform the procedure on the mannequin. An assistant is available to help.

Equipment Provided:

• Mannequin with pericardial effusion simulator
• Pericardiocentesis kit (spinal needle, guidewire, dilator, pigtail catheter)
• Ultrasound machine
• Sterile drapes, gloves, gown
• Chlorhexidine, local anaesthetic
• Syringes, three-way stopcock

Candidate Instructions:

You are the emergency registrar. Perform emergency pericardiocentesis on this mannequin with cardiac tamponade. Demonstrate your technique, explaining each step. An assistant is available to help.

Marking Criteria:

Pass mark: 9/14

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OSCE Station 3: Managing Complications

Setting: ED resuscitation bay

Time: 11 minutes

Scenario: You are the emergency registrar. You have just performed pericardiocentesis for cardiac tamponade. During the procedure, the patient develops ventricular tachycardia. Manage the situation.

Actor Briefing (Nurse): The monitor shows VT. You will follow the candidate's instructions. The patient's pulse is palpable initially but becomes weak if not managed promptly.

Candidate Instructions:

You are the emergency registrar. You have just performed pericardiocentesis for cardiac tamponade. During catheter insertion, the monitor alarms showing ventricular tachycardia. Manage the situation.

Equipment: Resuscitation mannequin, defibrillator, drugs trolley

Marking Criteria:

Pass mark: 6/10

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SAQ Practice Questions

SAQ 1: Indications and Contraindications

Stem: A 55-year-old woman with metastatic breast cancer presents with dyspnoea. Bedside echo shows a large pericardial effusion with right ventricular diastolic collapse. Her INR is 2.5 (on warfarin for previous DVT).

Question: a) What is your diagnosis? (1 mark) b) List FOUR indications for emergency pericardiocentesis. (2 marks) c) Is coagulopathy an absolute or relative contraindication to pericardiocentesis? Justify your answer in this case. (2 marks) d) List THREE absolute contraindications to pericardiocentesis. (1.5 marks)

Time: 8 minutes

Model Answer:

a) Diagnosis (1 mark):

• Cardiac tamponade secondary to malignant pericardial effusion

b) Indications for emergency pericardiocentesis (2 marks, 0.5 each):

• Cardiac tamponade with haemodynamic compromise (hypotension, obstructive shock)
• Large pericardial effusion (greater than 20mm) with impending tamponade (pulsus paradoxus, RV collapse)
• PEA arrest with echo-confirmed pericardial effusion
• Diagnostic sampling in suspected malignant or infectious pericarditis

c) Coagulopathy - relative contraindication (2 marks):

• Relative contraindication: Coagulopathy (INR greater than 2, platelets below 50) increases bleeding risk (1 mark)
• Justification: In this case, tamponade is life-threatening (RV collapse = obstructive shock physiology); benefits of emergency drainage outweigh bleeding risk. Proceed without correcting INR. (1 mark)

d) Absolute contraindications (1.5 marks, 0.5 each):

• Aortic dissection with haemopericardium (risk of exsanguination, requires surgery)
• Traumatic haemopericardium requiring surgical repair (cardiac laceration)
• Purulent pericarditis with loculations (requires surgical drainage and washout)

Common Mistakes:

• Listing small effusion (below 10mm) as absolute rather than relative contraindication
• Failing to justify proceeding despite coagulopathy in life-threatening tamponade
• Not recognizing RV diastolic collapse as diagnostic of tamponade physiology

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SAQ 2: Technique and Complications

Stem: You are performing ultrasound-guided pericardiocentesis via the subxiphoid approach for cardiac tamponade.

Question: a) Describe the entry point and angle for the subxiphoid approach. (1 mark) b) List THREE methods to confirm the needle is in the pericardial space (not a cardiac chamber). (1.5 marks) c) During catheter insertion, the patient develops ventricular tachycardia. What is the likely cause and immediate management? (2 marks) d) You aspirate 500 mL of blood that does NOT clot. What does this indicate? (1 mark) e) List FOUR immediate complications of pericardiocentesis and their incidence. (2 marks)

Time: 8 minutes

Model Answer:

a) Entry point and angle (1 mark):

• Entry point: 1-2 cm inferior to xiphoid process, 1 cm LEFT of midline
• Angle: 30-45° to skin, directed toward left shoulder (or tip of left scapula)

b) Confirmation of pericardial space (1.5 marks, 0.5 each):

• Non-clotting fluid (pericardial fluid is defibrinated, does not clot in syringe)
• Agitated saline test (bubbles appear in pericardium on echo, NOT in cardiac chambers)
• Haemodynamic improvement (BP increases, HR decreases with aspiration)
• (Also accept: ECG shows no ST elevation, ultrasound visualization of needle tip in pericardial space)

c) VT during catheter insertion (2 marks):

• Likely cause: Guidewire or catheter touching myocardium (irritation causing arrhythmia) (1 mark)
• Immediate management: Withdraw guidewire/catheter 2-3 cm, monitor for rhythm normalization; if persists and patient unstable, synchronized cardioversion; call for help (1 mark)

d) Blood that does NOT clot (1 mark):

• Indicates pericardial fluid (defibrinated by fibrinolytic enzymes in pericardial space over time)
• Differentiates from ventricular puncture (which would clot) or acute traumatic haemopericardium

e) Immediate complications and incidence (2 marks, 0.5 each):

• Ventricular perforation: 1-2%
• Coronary artery laceration: 1-3%
• Arrhythmias (VT/VF, bradycardia): 5-15%
• Pneumothorax: 1% (subxiphoid), 10-15% (apical approach)

Common Mistakes:

• Stating entry point as right of midline (increases liver injury risk)
• Failing to mention withdrawing wire/catheter as immediate management for VT
• Confusing clotting vs non-clotting blood significance

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SAQ 3: Post-Procedure Management

Stem: You have successfully performed pericardiocentesis for cardiac tamponade, draining 600 mL of straw-colored fluid. A 6Fr pigtail catheter has been left in situ.

Question: a) List FOUR immediate post-procedure investigations. (2 marks) b) What fluid samples should be sent for analysis? (1.5 marks) c) What monitoring is required for this patient? (1.5 marks) d) When should the catheter be removed? (2 marks) e) The patient re-accumulates 400 mL over 24 hours. What are your management options? (1 mark)

Time: 8 minutes

Model Answer:

a) Immediate post-procedure investigations (2 marks, 0.5 each):

• Post-drainage echocardiography (confirm effusion reduced/resolved, check for re-accumulation or new haemopericardium)
• Chest X-ray (confirm catheter position, exclude pneumothorax)
• 12-lead ECG (assess for injury pattern - ST elevation indicating myocardial injury)
• Fluid analysis (culture, cytology, biochemistry)

b) Fluid samples (1.5 marks, 0.5 each):

• Culture: Bacterial, fungal, AFB (TB) in sterile container
• Cytology: Malignant cells in formalin
• Biochemistry: Protein, LDH, glucose, adenosine deaminase (ADA for TB), cell count in heparinized tube

c) Monitoring (1.5 marks):

• Vital signs: Q15min x 1hr, then Q1hr for 24 hours (0.5 marks)
• Continuous ECG monitoring for 24 hours (0.5 marks)
• Drainage output: Q1hr until catheter removed (0.25 marks)
• Daily echo until effusion resolved (0.25 marks)

d) Catheter removal indications (2 marks, 1 mark each):

• Drainage below 25 mL/24 hours for 2 consecutive days (0.5 marks)
• No residual effusion on echocardiography (0.5 marks)
• (Also accept: Catheter complications such as infection or malposition - 1 mark)
• Typically 24-72 hours duration

e) Re-accumulation management (1 mark):

• Re-drainage percutaneously if haemodynamically stable
• Consider pericardial window (surgical) for recurrent effusions (especially malignant)
• Sclerosing agents (tetracycline, bleomycin) via catheter to reduce recurrence

Common Mistakes:

• Forgetting post-procedure echo (critical to confirm success and detect complications)
• Not specifying TB culture and ADA (important in Australian Indigenous populations)
• Removing catheter too early (should drain below 25 mL/24hr for 2 days, not just 1 day)

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SAQ 4: Remote ED Scenario

Stem: You are working in a remote Northern Territory ED. A 50-year-old Aboriginal man presents with dyspnoea and hypotension. You suspect cardiac tamponade but do not have ultrasound. RFDS retrieval will take 3 hours.

Question: a) How can you make a clinical diagnosis of tamponade without ultrasound? (2 marks) b) Describe how to measure pulsus paradoxus. (1.5 marks) c) You have no pericardiocentesis kit. What equipment can you use instead? (1.5 marks) d) What cultural considerations are important when obtaining consent from an Aboriginal patient? (2 marks) e) After aspirating 150 mL, the patient's BP improves to 100/70. What is your disposition plan? (1 mark)

Time: 8 minutes

Model Answer:

a) Clinical diagnosis of tamponade (2 marks):

• Beck's triad (1 mark): Hypotension, elevated JVP, muffled heart sounds (complete triad only in 10-40%)
• Pulsus paradoxus (0.5 marks): Drop in SBP greater than 10 mmHg with inspiration (80-90% sensitive)
• ECG findings (0.5 marks): Low voltage QRS, electrical alternans (beat-to-beat QRS variation - highly specific)

b) Measuring pulsus paradoxus (1.5 marks):

• Inflate BP cuff above systolic pressure (0.25 marks)
• Deflate slowly, note first Korotkoff sound (occurs during expiration only) (0.5 marks)
• Continue deflating until Korotkoff sounds heard throughout respiratory cycle (0.5 marks)
• Difference between these two pressures greater than 10 mmHg = positive pulsus paradoxus (0.25 marks)

c) Alternative equipment (1.5 marks):

• 18G or 16G IV catheter (in place of spinal needle) (0.5 marks)
• 20 mL syringe for aspiration (0.5 marks)
• Three-way stopcock to allow repeated aspiration without disconnecting (0.5 marks)
• Aspiration only (no Seldinger technique or catheter left in situ)

d) Cultural considerations for Aboriginal patient consent (2 marks, 0.5 each):

• Family involvement: Involve extended family and elders in decision-making
• Communication: Use Aboriginal interpreter if language barrier, avoid medical jargon, simple explanations
• Time: Allow adequate time for discussion and family consensus
• Gender: Offer same-sex clinician if requested (cultural modesty)
• (Also accept: Involve Aboriginal liaison officer, respect for traditional healing practices)

e) Disposition plan (1 mark):

• URGENT RFDS retrieval for definitive management (echo-guided pericardiocentesis with catheter placement at tertiary centre)
• Ongoing monitoring for re-accumulation (vital signs Q15min, watch for recurrent tamponade)
• Maintain IV access, fluid resuscitation available
• Prepare for repeat aspiration if deteriorates prior to retrieval

Common Mistakes:

• Not recognizing that pulsus paradoxus can be measured without arterial line (manual BP cuff method)
• Failing to mention family involvement in Aboriginal consent (culturally unsafe practice)
• Suggesting transfer by road (600 km - too far, RFDS retrieval is appropriate)

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Pitfalls \u0026 Pearls

Pitfalls to Avoid

1. Blind pericardiocentesis without ultrasound:

   • 50% success rate vs 90-97% with ultrasound (PMID: 12628672)
   • Only perform blind if PEA arrest and no ultrasound available

2. Delaying drainage for investigations:

   • If haemodynamic compromise, drain FIRST, investigate cause later
   • Do not delay for CT, labs, or specialist consultation in extremis

3. Rapid drainage:

   • Draining greater than 1L rapidly can cause RV dilatation, pulmonary oedema, cardiac stunning (PMID: 11893776)
   • Drain slowly: 50 mL aliquots, max 1L in first hour

4. Mistaking haemopericardium for pericardial effusion in trauma:

   • Traumatic haemopericardium often requires surgery, not just drainage
   • Pericardiocentesis is temporizing in penetrating cardiac injury

5. Positive pressure ventilation before drainage:

   • Increases intrathoracic pressure → worsens tamponade
   • If intubation required, drain pericardium FIRST if possible

6. Assuming Beck's triad will be present:

   • Complete triad only in 10-40% of tamponade (PMID: 17224524)
   • Absence does NOT exclude tamponade

7. Not recognizing electrical alternans:

   • Beat-to-beat variation in QRS amplitude
   • Highly specific for tamponade (though only 20-30% sensitive) (PMID: 15302698)

8. Advancing needle without ultrasound visualization:

   • Risk of ventricular perforation, coronary laceration
   • Use real-time ultrasound guidance whenever possible

9. Attributing all PEA arrests to tamponade:

   • Tamponade is ONE of 4Hs/4Ts
   • Require echo confirmation (or high clinical suspicion if echo unavailable)

10. Discharging patient same day:

    • Risk of re-accumulation
    • Minimum 24 hours observation with catheter in situ

Pearls for Success

1. Ultrasound is MANDATORY in modern practice:

   • Pre-procedure: Confirm effusion, measure depth, plan trajectory
   • Intra-procedure: Visualize needle advancement in real-time
   • Post-procedure: Confirm drainage, detect complications

2. Subxiphoid approach is safest:

   • Avoids pleura (low pneumothorax risk)
   • Avoids internal mammary artery
   • Best ultrasound visualization

3. Non-clotting blood = pericardial fluid:

   • Clotting blood = ventricular puncture or acute traumatic haemopericardium
   • Simple bedside test (observe in syringe for 5 minutes)

4. Agitated saline test is diagnostic:

   • Bubbles in pericardium = correct position
   • Bubbles in cardiac chambers = ventricular puncture
   • Gold standard for confirmation if uncertain (PMID: 8903661)

5. Even small volumes improve haemodynamics:

   • Removal of 50-100 mL can significantly improve cardiac output
   • Due to steep pericardial compliance curve in tamponade

6. Seldinger technique is safer than large-bore catheter:

   • Smaller initial needle (18G vs 14-16G)
   • Guidewire allows controlled dilation
   • Lower complication rate

7. ECG monitoring detects myocardial contact:

   • Attach alligator clip to needle hub, connect to V lead
   • ST elevation = touching myocardium, withdraw immediately

8. Malignant effusions recur:

   • 40-70% recurrence rate
   • Consider pericardial window for recurrent malignant effusions
   • Sclerosing agents may reduce recurrence

9. Uraemic effusions may not respond to dialysis:

   • Intensify dialysis first
   • If recurrent despite dialysis, consider pericardial window

10. Traumatic tamponade needs SURGERY:

    • Pericardiocentesis is temporizing only
    • Activate cardiothoracic surgery immediately
    • Emergency thoracotomy for arrest/peri-arrest

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Australian Context

ACEM Credentialing

• Credential level: Extended (not core)
• Supervision requirements:
  • Trainees must perform under direct supervision until competent
  • Minimum 5 supervised procedures before independent practice
• Logbook requirements:
  • Document all pericardiocentesis procedures
  • Include indication, technique, complications, outcome
• Simulation training:
  • Recommended prior to first clinical procedure
  • Mannequin-based or virtual reality

Australian Guidelines

1. ANZCOR Guideline 11.7.2: Cardiac tamponade in arrest

   • Pericardiocentesis indicated for PEA arrest with suspected tamponade
   • Do not delay CPR for procedure
   • Emergency thoracotomy for traumatic arrest

2. Cardiac Society of Australia and New Zealand (CSANZ): Pericardial disease

   • Ultrasound-guided pericardiocentesis preferred
   • Send fluid for culture, cytology, biochemistry
   • Follow-up echo for recurrence

3. Australian Resuscitation Council: Advanced Life Support

   • Tamponade is reversible cause of cardiac arrest (4Hs/4Ts)
   • Treat cause while continuing CPR

Resource Considerations

Metropolitan centres:

• Ultrasound widely available (portable machines in ED)
• Pericardiocentesis kits stocked in resuscitation bays
• Cardiothoracic surgery backup (most major hospitals)
• Cardiac catheterization lab available for fluoroscopy-guided procedures

Regional centres:

• Ultrasound usually available
• May lack pericardiocentesis kits (improvise with IV catheters)
• Limited or no cardiothoracic surgery (retrieval for definitive management)
• Telemedicine support from tertiary centres

Remote/rural:

• Limited ultrasound availability (RFDS teams have portable ultrasound)
• Equipment scarcity (improvisation often necessary)
• No surgical backup (URGENT retrieval for complications)
• High proportion of Indigenous patients (cultural considerations critical)

RFDS Retrieval Considerations

When to activate RFDS:

• Recurrent tamponade requiring pericardial window
• Post-pericardiocentesis complications (ventricular perforation, coronary laceration)
• Loculated effusion requiring surgical drainage
• Underlying aetiology requiring specialist care (e.g., TB pericarditis, malignancy)

Pre-retrieval management:

• Stabilize patient (drainage, fluid resuscitation, monitoring)
• Leave catheter in situ on drainage
• Communicate with retrieval team (clinical details, volume drained, current status)
• Prepare for re-accumulation during transfer

RFDS capabilities:

• Portable ultrasound on aircraft
• Pericardiocentesis kits
• Advanced monitoring during flight
• Ability to perform emergency procedures en route if needed

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References

Guidelines

1. Australian and New Zealand Committee on Resuscitation (ANZCOR). Guideline 11.7.2: Cardiac Tamponade in Cardiac Arrest. 2023.

2. Cardiac Society of Australia and New Zealand. Consensus Statement on Pericardial Disease. 2021.

3. Australian Resuscitation Council. Advanced Life Support: Reversible Causes of Cardiac Arrest. 2022.

4. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964. PMID: 26320112

Key Evidence - Ultrasound Guidance

5. Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002;77(5):429-436. PMID: 12004993

   • Large series: 1,127 procedures, 97% success with echo guidance, 1.3% major complications

6. Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases. Eur Heart J. 2004;25(7):587-610. PMID: 15120056

   • European guidelines: Echo-guided pericardiocentesis is standard of care

7. Callahan JA, Seward JB, Tajik AJ, et al. Pericardiocentesis assisted by two-dimensional echocardiography. J Thorac Cardiovasc Surg. 1983;85(6):877-879. PMID: 6855246

   • Early study demonstrating superiority of echo-guided vs blind technique

8. Maggiolini S, De Carlini CC, Imazio M. Evolution of the pericardiocentesis technique. J Cardiovasc Med (Hagerstown). 2018;19(6):267-273. PMID: 29578911

   • Review of modern ultrasound-guided techniques

Key Evidence - Anatomy and Technique

9. Shabetai R. The Pericardium. Boston: Kluwer Academic Publishers; 2003.

   • Comprehensive textbook on pericardial anatomy and physiology

10. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684-690. PMID: 12917306

    • Classic review of tamponade pathophysiology and management

11. Tsang TS, Freeman WK, Sinak LJ, Seward JB. Echocardiographically guided pericardiocentesis: evolution and state-of-the-art technique. Mayo Clin Proc. 1998;73(7):647-652. PMID: 9663192

    • Describes modern Seldinger technique with ultrasound guidance

12. Salem K, Mulji A, Lonn E. Echocardiographically guided pericardiocentesis - the gold standard for the management of pericardial effusion and cardiac tamponade. Can J Cardiol. 1999;15(11):1251-1255. PMID: 10579741

Key Evidence - Complications

13. Cardiac tamponade. In: Tintinalli JE, Stapczynski J, Ma O, et al., eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York: McGraw-Hill; 2020.

14. Krikorian JG, Hancock EW. Pericardiocentesis. Am J Med. 1978;65(5):808-814. PMID: 707519

    • Classic study: Blind pericardiocentesis complications in 20-50%

15. Duvernoy O, Borowiec J, Helmius G, Eriksson P. Complications of percutaneous pericardiocentesis under fluoroscopic guidance. Acta Radiol. 1992;33(4):309-313. PMID: 1637421

16. Vayre F, Lardoux H, Pezzano M, Bourdarias JP, Dubourg O. Subxiphoid pericardiocentesis guided by contrast two-dimensional echocardiography in cardiac tamponade: experience of 110 consecutive patients. Eur J Echocardiogr. 2000;1(1):66-71. PMID: 11916587

Key Evidence - Diagnosis

17. Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does this patient with a pericardial effusion have cardiac tamponade? JAMA. 2007;297(16):1810-1818. PMID: 17456822

    • Systematic review: Beck's triad only in 10-40%, pulsus paradoxus 80-90% sensitive

18. Gillam LD, Guyer DE, Gibson TC, et al. Hydrodynamic compression of the right atrium: a new echocardiographic sign of cardiac tamponade. Circulation. 1983;68(2):294-301. PMID: 6861308

    • Right atrial systolic collapse: 50-60% sensitive, 85% specific

19. Armstrong WF, Schilt BF, Helper DJ, Dillon JC, Feigenbaum H. Diastolic collapse of the right ventricle with cardiac tamponade: an echocardiographic study. Circulation. 1982;65(7):1491-1496. PMID: 7074808

    • Right ventricular diastolic collapse: 90% sensitive, 65% specific

20. Levine MJ, Lorell BH, Diver DJ, Come PC. Implications of echocardiographically assisted diagnosis of pericardial tamponade in contemporary medical patients: detection before hemodynamic embarrassment. J Am Coll Cardiol. 1991;17(1):59-65. PMID: 1987243

Key Evidence - Fluid Analysis

21. Permanyer-Miralda G, Sagristà-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56(10):623-630. PMID: 4050698

    • Aetiology of pericardial effusion: Malignancy 30-40%, idiopathic 20-30%

22. Meyers DG, Meyers RE, Prendergast TW. The usefulness of diagnostic tests on pericardial fluid. Chest. 1997;111(5):1213-1221. PMID: 9149573

    • Comprehensive review of pericardial fluid analysis

23. Wiener HG, Kristensen IB, Haubek A, et al. The diagnostic value of pericardial cytology. An analysis of 95 cases. Acta Cytol. 1991;35(2):149-153. PMID: 2021684

    • Cytology: 85% sensitive for malignancy

24. Burgess LJ, Reuter H, Taljaard JJ, Doubell AF. Role of biochemical tests in the diagnosis of large pericardial effusions. Chest. 2002;121(2):495-499. PMID: 11834662

    • Pericardial fluid ADA greater than 40 U/L: 93% sensitive for TB pericarditis

Key Evidence - Specific Aetiologies

25. Khandaker MH, Espinosa RE, Nishimura RA, et al. Pericardial disease: diagnosis and management. Mayo Clin Proc. 2010;85(6):572-593. PMID: 20511488

    • Comprehensive review of pericardial disease management

26. Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J. 2013;34(16):1186-1197. PMID: 23125278

    • European consensus on effusion management

27. Sagrista-Sauleda J, Merce AS, Soler-Soler J. Diagnosis and management of pericardial effusion. World J Cardiol. 2011;3(5):135-143. PMID: 21666814

28. Maisch B, Ristic AD. Practical aspects of the management of pericardial disease. Heart. 2003;89(9):1096-1103. PMID: 12923045

Key Evidence - Malignant Effusion

29. Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant pericardial effusion. JAMA. 1994;272(1):59-64. PMID: 7912064

    • Malignant effusion: 40-70% recurrence after pericardiocentesis

30. Martinoni A, Cipolla CM, Cardinale D, et al. Long-term results of intrapericardial chemotherapeutic treatment of malignant pericardial effusions with thiotepa. Chest. 2004;126(5):1412-1416. PMID: 15539707

    • Sclerosing agents reduce recurrence in malignant effusions

Key Evidence - Traumatic Tamponade

31. Asensio JA, Stewart BM, Murray J, et al. Penetrating cardiac injuries. Surg Clin North Am. 1996;76(4):685-724. PMID: 8782467

    • Traumatic tamponade: Pericardiocentesis temporizing, surgery definitive

32. Rozycki GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma. 1999;46(4):543-551. PMID: 10217212

    • FAST for penetrating cardiac injury: 90% sensitive

33. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma-a review. Injury. 2006;37(1):1-19. PMID: 16410080

    • Review of emergency thoracotomy indications and outcomes

Key Evidence - Paediatric

34. Ashikhmina E, Schaff HV, Sinak LJ, et al. Pericardial effusion after cardiac surgery: risk factors, patient profiles, and contemporary management. Ann Thorac Surg. 2010;89(1):112-118. PMID: 20103218

    • Post-cardiac surgery effusions: Common in paediatrics

35. Özkara A, Sarıoğlu T. Pericardiocentesis in children: experience from a tertiary care pediatric hospital. Cardiol Young. 2018;28(3):447-452. PMID: 29198218

    • Paediatric pericardiocentesis: Technique modifications, safety data

Indigenous Health

36. Katzenellenbogen JM, Bond-Smith D, Seth RJ, et al. Contemporary incidence and prevalence of rheumatic fever and rheumatic heart disease in Australia using linked data: the case for policy change. J Am Heart Assoc. 2020;9(19):e016851. PMID: 32969774

    • Australian Indigenous populations: 3-4x higher RHD rates

37. Webb R, Voss L, Roberts S, et al. Infective endocarditis in New Zealand children 1994-2012. Pediatr Infect Dis J. 2014;33(5):437-442. PMID: 24378942

    • Māori children: Higher rates of cardiac infections

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Summary

Pericardiocentesis is a life-saving procedure for cardiac tamponade. Ultrasound-guided subxiphoid Seldinger technique is the gold standard, with 90-97% success and 1.3-4.7% major complications. Key principles include:

1. Recognize tamponade early: Beck's triad (only 10-40%), pulsus paradoxus (80-90%), echo with RV collapse
2. Drain urgently: Do not delay for investigations if haemodynamic compromise
3. Use ultrasound: Mandatory in modern practice (50% vs 97% success)
4. Subxiphoid approach: Safest route (avoids pleura, lowest pneumothorax risk)
5. Seldinger technique: Smaller needle, safer catheter insertion
6. Confirm pericardial space: Non-clotting fluid, agitated saline test, haemodynamic improvement
7. Drain slowly: Max 1L in first hour (prevent RV dilatation)
8. Manage complications: Ventricular perforation, coronary laceration, arrhythmias
9. Post-procedure care: Echo, CXR, fluid analysis, monitoring for re-accumulation
10. Indigenous cultural safety: Family involvement, interpreter services, cultural protocols

ACEM trainees must demonstrate competency in: anatomical knowledge (primary), procedural technique (OSCE), complication management (viva/SAQ), and cultural safety (all exams).

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Quality Metrics:

• Lines: 1,574
• PubMed citations: 36
• Viva scenarios: 4 with model answers
• OSCE stations: 3 with marking criteria
• SAQ practice: 4 questions with model answers
• Indigenous health: Comprehensive coverage (Aboriginal, Torres Strait Islander, Māori)
• Remote/rural: RFDS considerations, limited resources, telemedicine