Cardiac tamponade

Diagnosis: The malignant cardiac tamponade — the hypotension, the raised JVP, the quiet heart sounds (the modified Beck triad), and the echo confirmation (the large effusion, the right ventricular diastolic collapse, the plethoric IVC). This is the obstructive shock from the tamponade, and the drainage is the definitive treatment.

Resuscitation (the temporising bridge):

• ABCDE, oxygen, two large-bore cannulae, the cardiac monitoring, the arterial blood gas.
• Cautious fluid bolus (250 to 500 mL crystalloid) to raise the filling pressure above the pericardial pressure and improve the preload — reassess, avoid the over-load.
• Vasopressor support (the noradrenaline) as the bridge.
• Avoid the positive-pressure ventilation unless the drainage team is ready — the PPV drops the venous return and precipitates the arrest.
• The bloods (the group and save, the coagulation, the renal), the ECG (the low voltage, the electrical alternans).^[1]

Definitive management: The echo-guided pericardiocentesis — the subxiphoid approach under the echocardiographic guidance, the aspiration of the fluid, the drain left in situ. The fluid is sent for the cytology (the malignancy), the culture, the biochemistry.^[2]

Disposition: The cardiac monitoring and the high-dependency or the intensive care. The recurrence is likely in the malignant effusion, so the surgical pericardial window or the pericardiostomy may be needed for the definitive prevention. The oncology team is involved for the underlying disease.^[1]