30/11/2025
EMERGENCY PERICARDIOCENTESIS
SUB XIPHOIDAL APPROACH
The extrapleural subcostal pericardiocentesis approach is performed as follows
Introduce the needle substernally 1 cm inferior to the left xiphocostal angle. Once beneath the cartilage cage, lower the needle so it approximates a 30-degree inclination with the chest wall...
Aim the needle toward the left mid-clavicle and advance it slowly while continuously aspirating. If no fluid is aspirated, the needle should be withdrawn promptly and redirected. In the absence of ultrasound guidance, withdraw the needle to the skin and redirect it along a deeper slightly posterior trajectory. The required depth of insertion is affected by the patient's anatomy. In most cases, a 7 to 9 cm needle is adequate, but longer needles (up to 12 cm) may be needed for patients with more anterior thoraco-abdominal soft tissue (eg, class 2 or 3 obesity). In infants and small children, 4 cm (1.5 inch) needles are sufficient.
If no fluid is aspirated on the second attempt, withdraw the needle to the skin and redirect it 10 degrees to the patient's right of the last dry needle aspiration path. Perform systematic redirected aspirations by working from the patient's left to right until the needle is aimed toward the right neck...
Parasternal
The left sternal border is the landmark for a parasternal approach Left parasternal access is most frequently used.
Insert the needle perpendicular to the skin and over the cephalad border of the fifth or sixth rib immediately adjacent to the sternal margin. The cardiac notch of the left lung exposes the pericardium at this site.
Avoid puncturing more laterally (greater than 1 cm) to prevent injury to the internal thoracic (mammary) vessels.
Apical
The apical pericardiocentesis approach reduces the risk of cardiac complications by taking advantage of the proximity to the thick walled left ventricle and the small apical coronary vessels
However, proximity to the left pleural space increases the risk for pneumothorax
The apical insertion site is at least 5 cm lateral to the parasternal approach within the fifth, sixth, or seventh intercostal space. Advance the needle over the cephalad border of the rib and towards the patient's right shoulder.
Copy from cardiovascular educations
