Site of Pericardiocentesis

[Miracoli]

A 52-year-old patient is admitted to the hospital with severe chest pain. ECG and radiographic examinations provide evidence of a signifi cant myocardial infarction and cardiac tamponade. An emergency pericardiocentesis is ordered. At which of the following locations will the needle best be inserted to relieve the tamponade?
A. Right seventh intercostal space in the midaxillary line
B. Left fifth intercostal space in the midclavicular line
C. Right third intercostal space, 1 inch lateral to the sternum
D. Left sixth intercostal space, 1 ⁄ 2 inch lateral to the sternum
E. Triangle of auscultation

Please explain

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[dfib slim]

A 52-year-old patient is admitted to the hospital with severe chest pain. ECG and radiographic examinations provide evidence of a signifi cant myocardial infarction and cardiac tamponade. An emergency pericardiocentesis is ordered. At which of the following locations will the needle best be inserted to relieve the tamponade?
A. Right seventh intercostal space in the midaxillary line
B. Left fifth intercostal space in the midclavicular line
C. Right third intercostal space, 1 inch lateral to the sternum
D. Left sixth intercostal space, 1 ⁄ 2 inch lateral to the sternum
E. Triangle of auscultation

Please explain

I believe B is the apical approach.
A and C seems too far to the right, D seems too low to be parasternal and E is where you hear lung sounds.

 

[Transposony]

There are two approaches-Parasternal or subxiphiod.
So, D seems to be the right answer.

 

[syoung]

https://en.wikipedia.org/wiki/Pericardiocentesis

 

[Miracoli]

There are two approaches-Parasternal or subxiphiod.
So, D seems to be the right answer.

Can you please explain the location for: 1) Parasternal approach and 2) subxiphiod approach?

 

[Transposony]

Can you please explain the location for: 1) Parasternal approach and 2) subxiphiod approach?

This is how they test your knowledge of surface anatomy.
The basic concept here is that you want to have the most direct access to the pericardium i.e. avoid going through the lung parenchyma.
In sub-xiphoid approach you are going through the diaphragm into the pericardial sac. You are taking advantage of the fact that pericardium is fused with the central tendon of the diaphragm here.
In parasternal approach you are going through the cardiac notch which lies along the fifth and sixth intercostal space of the left lung and where the pericardium is exposed.
Ideally it is done under US guidance except in an emergency.

http://www.nejm.org/doi/full/10.1056/NEJMvcm0907841

 

[Miracoli]

B is the given answer
but it should be left 5th ICS just lateral to the sternum. If the needle passes through left 5th ICS and mid-clavicular line", it will pierce the left lung and the apex of the heart.
https://books.google.com/books?id=S...ce, 1 ⁄ 2 inch lateral to the sternum&f=false

 

[dfib slim]

B is the given answer
but it should be left 5th ICS just lateral to the sternum. If the needle passes through left 5th ICS and mid-clavicular line", it will pierce the left lung and the apex of the heart.
https://books.google.com/books?id=SaFox394ZGkC&pg=PA27&dq=Left sixth intercostal space, 1 ⁄ 2 inch lateral to the sternum&hl=en&sa=X&ei=iDXIVLaQLuHdmAX5nYCgCw&ved=0CB8Q6AEwAA#v=onepage&q=Left sixth intercostal space, 1 ⁄ 2 inch lateral to the sternum&f=false

From Uptodate

Subcostal (subxiphoid) — The extrapleural subcostal pericardiocentesis approach is performed as follows (figure 4) [2,9,19,30,31]:

●Introduce the needle substernally 1 cm inferior to the left xiphocostal angle. Once beneath the cartilage cage, lower the needle so it approximates a 15 to 30 degree angle with the abdominal wall.



●Aim the needle toward the left shoulder 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 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 obese patients. 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 15 degrees to the patient’s right of the last dry needle path. Perform systematic redirected aspirations by working from the patient's left to right until the needle is aimed toward the right shoulder.



Ultrasound guidance generally enables the clinician to avoid inserting the needle into other organs. However, interposition of the left liver lobe is often recognized on subcostal imaging and the lobe may be traversed intentionally during pericardiocentesis, if an alternative site is not available.

Parasternal — The left sternal border is the landmark for a parasternal approach (figure 5). 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 mammary artery.



An analogous right parasternal approach is occasionally used when ultrasound predicts superior access from this site.

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 (figure 6). However, proximity to the left pleural space increases the risk for pneumothorax [32].

The apical insertion site is at least 5 centimeters 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.