J Korean Soc Emerg Med.  2000 Sep;11(3):331-338.

Is a Subcostal Approach Always Suitable for Emergency Pericardiocentesis?

• Kim SW
• Hwang SO
• Lee KH
• Cho JH
• Kang KH
• Moon JB
• Lee SW
• Yoon J
• Choe KH
• Kim YS

Abstract

BACKGROUND: The aim of this study was to determine whether the conventional subcostal approach is suitable for emergency pericardiocentesis in patients with cardiac tamponade or impending cardiac tamponade.
METHODS
This study was a prospective, observational study conducted at the emergency department of a tertiary hospital. Patients who had symptomatic pericardial effusion and who needed emergency pericardiocentesis in the emergency department were included in this study. We measured the epicardium-to-pericardium distance at the subcostal, parasternal, and apical area with two-dimensional echocardiography to determine the appropriate puncture site for pericardiocentesis. An epicardium-to-pericardium distance of more than 1.0cm was considered as the primary safety factor in determining the puncture site for pericardiocentesis. The skin-to-pericardium distance was considered as secondary safety factor.
RESULTS
Ninety-five consecutive patients(55 males and 40 females; total mean age: 53 year old) with cardiac tamponade or impending cardiac tamponade were enrolled in this study. The puncture site for pericardiocentesis, as determined by echocardiography, was the subcostal area in 43 patients(45%), the apical area in 40 patients(42%), the left parasternal area in 11 patients(12%), and the right parasternal area in one patient(1%). Pericardiocentesis failed in 2 patients(2%) with the subcostal approach and in one patient(1%) with the apical approach. The average epicardium-to-pericardium distance was 31+/-21mm in patients with the subcostal approach and 21+/-8mm in patients with other approaches. There were no differences in the amount of pericardial fluid and in the intrapericardial pressure among patients groups according to puncture site. There were two procedure related complications: a puncture of the right ventricle with the subcostal approach and a ventricular tachycardia with the apical approach.
CONCLUSION
The puncture site for emergency pericardiocentesis should be determined by using two-dimensional echocardiography because approaches from other areas can be safer than the subcostal approach.

MeSH Terms

Cardiac Tamponade
Echocardiography
Emergencies*
Emergency Service, Hospital
Female
Heart Ventricles
Humans
Male
Observational Study
Pericardial Effusion
Pericardiocentesis*
Prospective Studies
Punctures
Tachycardia, Ventricular
Tertiary Care Centers