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Emergency Ultrasound

Tips & Tricks: “Normo-tensive” Tamponade with Tips for US-Guided Pericardiocentesis

By Rwo-Wen Huang, MD and Laleh Gharahbaghian, MD, FACEP

A 51-year-old male with metastatic non-small cell lung cancer presented with shortness of breath and bloating. He was normotensive (blood pressure 123/93), tachycardic (heart rate 110), tachypneic (respiratory rate 32), and hypoxic (oxygen saturation 97% on two liters of nasal cannula). Bedside ultrasound revealed a large pericardial effusion (PCE) with tamponade (Figure 1, Video 1, Video 2, Video 3, Video 4) and plethoric inferior vena cava (IVC, Figure 2, Video 5).

Tamponade1 Tamponade2
Figure 1 and 2: Tamponade showing Right Ventricular Collapse during Diastole and Plethoric IVC

Tamponade has been traditionally taught as a clinical diagnosis with the classic Beck’s triad of hypotension, distended neck veins, and distant heart sounds.1 However, these findings are not widely applicable to tamponade secondary to chronic PCE. Reviews show that hypotension is only present in 14-36% of patients with proven tamponade.2 When the effusion accumulates slowly, the body can maintain a stable blood pressure during the early stages. It compensates for increased intrapericardial pressure with pericardial stretching, elevated heart rate, enhanced systolic emptying, and augmented peripheral vascular resistance.3 This delicate balance can preserve the patient’s blood pressure until the tamponade reaches a critical point when the patient can acutely decompensate into hemodynamic instability.1 This scenario is especially common in malignancy, since cancer is one of the leading causes of chronic PCE with high mortality.1, 2, 4-6 The effusion can result from direct extension of the tumor, metastatic spread, or treatment complication.4 Therefore, it is crucial to realize that normotension does not exclude tamponade. Providers should rely on the more sensitive ultrasound findings, including right sided chambers collapse, full IVC, and respiratory variation of cardiac output (sonographic “pulsus paradoxus”).5

In addition to diagnosis, POCUS has the advantage of procedure planning and guidance. Rather than proceeding blindly, the provider can visualize where the PCE has the greatest pocket with the easiest access. Multiple studies have demonstrated that ultrasound guided pericardiocentesis has a higher success rate with fewer complications compared to traditional landmark technique.6-9 The subxiphoid view is generally considered the best window to evaluate for PCE. Besides the commonly used subxiphoid, transhepatic, parasternal, and apical approaches, recent literature explores novel methods to further improve efficacy and safety, such as in-plane, endobronchial, and endoscopic transesophageal ultrasound.8-11

Tips for US-Guided Pericardiocentesis

In this patient, we identified the best approach in the apical view. Here are a few tips for ultrasound guided pericardiocentesis:

  1. Probe: Use a phased array or curvilinear probe. Adjust the depth to optimize the view of PCE and right ventricle.
  2. Best view for pericardiocentesis: Wherever you see the most fluid (this is usually the parasternal or apical approach). Note the location and extent of the fluid pocket to anticipate the necessary angle and distance of needle entry.
  3. For the apical and parasternal approach, ensure the needle will enter above rib to avoid the neurovascular bundle. For the parasternal long axis approach, locate and avoid the internal mammary arteries, which are usually just lateral to the sternum.9
  4. Needle approach: An in-plane approach can maximize visualization of the needle path. Continue to aspirate as the needle advances.
  5. Seldinger technique: Once there is fluid return, insert the guidewire under direct sonographic visualization (Figure 3, Video 6). Place the catheter using standard Seldinger technique.
  6. Agitated saline: Injecting agitated saline can help confirm position.
  7. Connect to suction for large volume pericardiocentesis. 

Figure 3. Guidewire seen within pericardial sac

We removed more than 1,200 mL of hemorrhagic PCE from this patient via the apical approach. His vital signs and symptoms improved after the procedure (Video 7), and his level of care progressed from the intensive care unit to the oncology telemetry floor for further management. His CT later revealed metastatic pericardial nodules, which were likely the source of his effusion.


  1. Jacob S, Sebastian JC, Cherian PK, et al. Pericardial effusion impending tamponade: a look beyond Beck's triad. Am J Emerg Med. 2009 Feb;27(2):216-219. doi: 10.1016/j.ajem.2008.01.056.
  2. Kapoor T, Locurto M, Farina GA, et al. Hypotension is uncommon in patients presenting to the emergency department with non-traumatic cardiac tamponade. J Emerg Med. 2012 Feb;42(2):220-226. doi: 10.1016/j.jemermed.2010.05.071. Epub 2010 Aug 30.
  3. Brown J, MacKinnon D, King A, et al. Elevated arterial blood pressure in cardiac tamponade. N Engl J Med. 1992 Aug 13;327(7):463-466.
  4. Burazor I, Imazio M, Markel G, et al. Malignant pericardial effusion. Cardiology. 2013;124(4):224-232. doi: 10.1159/000348559. Epub 2013 Apr 5.
  5. Ceriani E, Cogliati C. Update on bedside ultrasound diagnosis of pericardial effusion. Intern Emerg Med. 2016 Apr;11(3):477-480. doi: 10.1007/s11739-015-1372-8. Epub 2016 Jan 8.
  6. Maggiolini S, Gentile G, Farina A, et al. Safety, efficacy, and complications of pericardiocentesis by real-time echo-monitored procedure. Am J Cardiol. 2016 Apr 15;117(8):1369-1374. doi: 10.1016/j.amjcard.2016.01.043. Epub 2016 Feb 3.
  7. Akyuz S, Zengin A, Arugaslan E, et al. Echo-guided pericardiocentesis in patients with clinically significant pericardial effusion: outcomes over a 10-year period. Herz. 2015 Apr;40 Suppl 2:153-159. doi: 10.1007/s00059-014-4187-x. Epub 2014 Dec 11.
  8. Law MA, Borasino S, Kalra Y, et al. Novel, long-axis in-plane ultrasound-guided pericardiocentesis for postoperative pericardial effusion drainage. Pediatr Cardiol. 2016 Oct;37(7):1328-1333. doi: 10.1007/s00246-016-1438-z. Epub 2016 Jul 15.
  9. Nagdev A, Mantuani D. A novel in-plane technique for ultrasound-guided pericardiocentesis. Am J Emerg Med. 2013 Sep;31(9):1424.e5-9. doi: 10.1016/j.ajem.2013.05.021. Epub 2013 Jul 1.
  10. Sharma RK, Khanna A, Talwar D. Endobronchial ultrasound: a new technique of pericardiocentesis in posterior loculated pericardial effusion. Chest. 2016 Nov;150(5):e121-e123. doi: 10.1016/j.chest.2016.03.013.
  11. Hashimoto Y, Inoue K. Endoscopic ultrasound-guided transesophageal pericardiocentesis: an alternative approach to a pericardial effusion. Endoscopy. 2016;48 Suppl 1 UCTN:E71-2. doi: 10.1055/s-0032-1326074. Epub 2016 Feb 18.

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