Position patient appropriately (head of bed elevated 30 degrees if possible).
Evaluate the pericardium in multiple views to determine the best area to attempt pericardiocentesis (i.e. the site at which the largest fluid collection is closest to the skin surface). Options include the subxiphoid and parasternal approach.
Identify anatomic landmarks (xiphoid process, left costal margin and left shoulder for subxiphoid approach).
Prepare the field with antiseptic as you are able based on patient presentation. Appropriately drape, don sterile gloves, and cover ultrasound transducer with a sterile covering, as time permits.
Anesthetize the area to be traversed with local anesthetic as the clinical situation permits.
Advance the needle along the trajectory of the ultrasound probe to the predetermined location. Aspirate during needle advancement and monitor for fluid return. Stop advancing once fluid is returned.
If there is any question of whether the needle tip is in the pericardial space, you can inject agitated saline through the catheter under direct ultrasound guidance. This will allow analysis of the location of the needle tip.
Aspirate pericardial fluid.
If necessary, place a pigtail drain using Seldinger technique as follows:
Advance a J-tipped guidewire through the needle and into the pericardium.
Remove the needle.
Incise the skin at the site of wire insertion with a scalpel. Make an incision large enough to accept the dilator and pigtail catheter.
Advance a dilator over the wire. Remove the dilator.
Advance a pigtail catheter over the wire and into the pericardium.
Remove the wire.
Drain the pericardial fluid.
Secure the drain by suturing it in place and apply appropriate dressing.
Order chest x-ray to evaluate for pneumothorax.