A 60-year-old man presents with cardiac tamponade and requires emergency subxiphoid pericardial window. He is tachypnoeic with a pulse of 120 bpm, blood pressure 90/60 mmHg, and pulsus paradoxus of 25 mmHg. Which anaesthetic approach is MOST appropriate?

• A Rapid sequence intubation with positive pressure ventilation
• B Intravenous induction with propofol and rocuronium, then controlled ventilation
• C Inhalational induction with sevoflurane and controlled ventilation
• D Awake fibreoptic intubation followed by spontaneous ventilation ✓

Explanation

In cardiac tamponade, positive pressure ventilation reduces venous return and can cause cardiovascular collapse. Maintaining spontaneous negative-pressure ventilation is critical. Awake fibreoptic intubation allows airway control without compromising the patient's compensatory spontaneous respiratory drive. Any agent causing vasodilation or myocardial depression can be fatal.

Reference: Miller's Anaesthesia, 9th ed.

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Written and medically reviewed by the StethoPrep medical team.