Pericardial Window
What the Examiner Expects
Creation of a small opening in the pericardium to diagnose and treat pericardial tamponade or effusion. The subxiphoid approach is performed through a small incision below the xiphoid process, dissecting through the linea alba to reach the pericardium extraperitoneally. A small window is excised and fluid is drained. The examiner expects you to recognize Beck's triad (hypotension, distended neck veins, muffled heart sounds) and know that FAST ultrasound has largely replaced the pericardial window for diagnosis in trauma. However, pericardial window remains indicated when FAST is equivocal, for recurrent effusions, or as a diagnostic step during exploration.
Key Examiner Focus Points
- Diagnostic and therapeutic for pericardial tamponade or effusion
- Subxiphoid approach: incision below xiphoid, access pericardium extraperitoneally
- Transdiaphragmatic approach during laparotomy: incise pericardium through central tendon
- If blood is found and the patient is stable, proceed to median sternotomy for cardiac exploration
- FAST (focused assessment with sonography for trauma) has largely replaced diagnostic pericardial window
Common Curveballs
During a trauma laparotomy, FAST was equivocal for pericardial fluid
Perform a transdiaphragmatic pericardial window: incise the central tendon of the diaphragm and inspect/open the pericardium. If hemopericardium is found, extend to a median sternotomy (not a thoracotomy through the diaphragm — poor access) for cardiac repair.
Patient with penetrating chest wound between the nipple lines has hemodynamic instability despite chest tube
This is the cardiac box — high suspicion for cardiac injury. FAST should be performed immediately. If positive for pericardial fluid, proceed to OR for median sternotomy and cardiac exploration. If equivocal and unstable, ED thoracotomy or operative exploration is warranted.
Practice this topic with an AI-powered mock oral exam.
Browse Practice Cases