Snapshot A 17-year-old male is stabbed in the left side of his chest just medial to the nipple. His blood pressure is 90/60 and his pulse is 130. On inspiration his JVP increases and his peripheral pulses and blood pressure decrease. Breath sounds and CXR are unremarkable. After 2L of isotonic saline, his blood pressure remains low, but his CVP rises to 32. Introduction Fluid collection in the pericardial sac that restricts ventricular filling leads to a decrease in cardiac output symptoms and severity related to rate of fluid collection (not size of effusion) Risk factors/causes include pericarditis malignancy SLE tuberculosis penetrating trauma most often medial to the left nipple Cardiac tamponade should be considered in any patient who is hemodynamically unstable unresponsive to fluid resuscitation Presentation Symptoms severe chest pain dyspnea fatigue anxiety tachycardia tachypnea can rapidly lead to shock and death Physical exam Becks triad hypotension distant heart sounds distended jugular veins narrow pulse pressure pulsus paradoxus >10 mmHg drop in BP on inspiration Kussmaul's sign elevated CVP on inspiration Evaluation EKG electrical alterans is diagnositic beat-to-beat alternating of QRS magnitude decreased amplitude CXR may reveal enlarged, globular heart Echocardiogram shows RA/RV collapse in diastole Differential Severe MI, tension pneumothorax (absent breath sounds, hyperresonant percussion) Treatment Nonoperative urgent pericardiocentesis & aggresive volume expansion pericardiocentesis via subxyphoid method critical for immediate relief of pericardial constriction will produce aspirate of nonclotting blood volume expansion bolus IV fluids to boost cardiac output Operative surgical exploration indications perform following pericardiocentesis to identify the source of bleeding balloon pericardiotomy and pericardial window indications may be warranted in cases of decompensation Prognosis, Prevention, and Complications Prognosis very poor without immediate intervention Prevention possible with early identification of high-risk patients aided by proper post-traumatic screening FAST ultrasound exam necessitates careful following of vital signs Complications unidentified cardiac tamponade can rapidly lead to shock and death