What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance?

BACKGROUND:Traditionally performed using a subxiphoid approach,the increasing use of point-of-care ultrasound in the emergency department has made other approaches(parasternal and apical)for pericardiocentesis viable.The aim of this study is to identify the ideal approach for emergency-physician-performed ultrasound-guided pericardiocentesis as determined by ultrasound image quality,distance from surface to pericardial fl uid,and likely obstructions or complications.METHODS:A retrospective review of point-of-care cardiac ultrasound examinations was performed in two urban academic emergency departments for the presence of pericardial eff usions.The images were reviewed for technical quality,distance of eff usion from skin surface,and predicted complications.RESULTS:A total of 166 pericardial effusions were identified during the study period.The mean skin-to-pericardial fl uid distance was 5.6 cm(95%confi dence interval[95%CI]5.2-6.0 cm)for the subxiphoid views,which was signifi cantly greater than that for the parasternal(2.7 cm[95%CI 2.5-2.8 cm],P<0.001)and apical(2.5 cm[95%CI 2.3-2.7 cm],P<0.001)views.The subxiphoid view had the highest predicted complication rate at 79.7%(95%CI 71.5%-86.4%),which was signifi cantly greater than the apical(31.9%;95%CI 21.4%-44.0%,P<0.001)and parasternal(20.2%;95%CI 12.8%-29.5%,P<0.001)views.CONCLUSIONS:Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach.The distance from skin to fl uid collection is the least in both of these views.

Clinical and historical features of emergency department patients with pericardial effusions

BACKGROUND: Diagnosing pericardial effusion is critical for optimal patient care. Typically, clinicians use physical examination ? ndings and historical features suggesting pericardial effusion to determine which patients require echocardiography. The diagnostic characteristics of these tools are not well described. The objective of this study is to determine the prevalence of historical features and sensitivity of clinical signs to inform clinicians when to proceed with echocardiogram.METHODS: A retrospective review of point-of-care echocardiograms performed over a two and a half year period in two emergency departments were reviewed for the presence of a pericardial effusion. Patient charts were reviewed and abstracted for presenting symptoms, historical features and clinical findings. The prevalence of presenting symptoms and historical features and the sensitivity of classic physical examination ? ndings associated with pericardial effusion and tamponade were determined.RESULTS: One hundred and fifty-three patients with pericardial effusion were identified. Of these patients, the most common presenting complaint was chest pain and shortness of breath. Patients had no historical features that would suggest pericardial effusion in 37.5% of cases. None of the patients with pericardial effusion or pericardial tamponade had all of the elements of Beck's triad. The sensitivity of Beck's triad was found to be 0(0%–19.4%). The sensitivity for one ? nding of Beck's triad to diagnose pericardial tamponade was 50%(28.0%–72.0%).CONCLUSION: History and physical examination findings perform poorly as tests for the diagnosis of pericardial effusion or pericardial tamponade. Clinicians must liberally evaluate patients suspected of having a pericardial effusion with echocardiography.