START

❶ Call for help and inform clinical team of problem. Note the time.

❷ If indicated, start CPR immediately.

❸ Give 100% oxygen, ventilate and exclude tension pneumothorax: • Maintain the airway and, if necessary, secure it with tracheal tube

❹ Rapid diagnosis and rapid drainage are vital, so:  

• Call for ultrasound machine.
• Call for pericardiocentesis kit (eg 18G Luer spinal needle + 3-way tap + 20 ml syringe or a purpose made kit). 
• Call for cardiac arrest trolley.
• Diagnostic features are shown in Box A.

❺ Consider whether there is time to wait for someone with expertise in pericaridiocentesis, or whether thoracotomy is a better treatment option.

❻ Consider the following temporising measures: 

• Fluid bolus (Adult: 500 - 1000 ml, Child: 20 ml.kg^-1) .
• Inotropic drugs.
• Low tidal volume, low/no PEEP ventilation strategy.

❼ If clinically indicated, perform pericardiocentesis (Box B).

❽ After pericardiocentesis, re-assess using ultrasound examination and vital signs.

❾ Reassess continually in case tamponade recurs.

❿ Plan definitive management of underlying cause, including specialist referral.

⓫ Plan transfer of the patient to an appropriate critical care area.

Box A: DIAGNOSTIC FEATURES

ULTRASOUND DIAGNOSIS IS THE PREFERRED TECHNIQUE

• Unexplained dyspnoea/tachypnoea and agitation if conscious
• At least one of ‘Beck’s Triad’: 
  • Jugular venous distension
  • Muffled heart sounds 
  • Hypotension
• Other signs: Pulsus paradoxus; ECG → low voltage QRS / electrical alternans / pulseless electrical activity;  chest X-ray → enlarged cardiac silhouette

Box B: EMERGENCY PERICARDIOCENTESIS (sub-xiphoid approach)

ULTRASOUND GUIDANCE IS THE PREFERRED TECHNIQUE WARNING: Myocardial rupture, aortic dissection and severe bleeding disorder are relative contraindications.

• Identify tip of xiphoid
• Prep and drape overlying skin
• Infiltrate local anaesthetic (if necessary and if time)  
• Ideally use ultrasound to identify pericardial fluid 
• Insert pericardiocentesis needle immediately to left of tip of xiphoid
• Attach 3-way tap and 20 ml syringe
• Direct needle generally toward left shoulder but using ultrasound to direct needle toward the largest pericardial collection
• Aspirate and drain – aspiration of a small volume may cause a dramatic clinical improvement 

Box C: CRTICAL CHANGES

Cardiac arrest → 1-A