A 25-year-old man sustains a stab wound to the left anterior chest in the 'cardiac box' (area between the clavicles, nipples, and sternal notch). He is brought to A&E with BP 70/40 mmHg, heart rate 128/min, distended neck veins, and muffled heart sounds. Chest X-ray shows a widened cardiac silhouette. What is the immediate surgical intervention?
- A Immediate median sternotomy in the operating theatre
- B Echocardiography to confirm pericardial effusion before intervention
- C FAST ultrasound and CT scan of the chest
- D Emergency pericardiocentesis or resuscitative thoracotomy ✓
Explanation
Beck's triad (hypotension, distended neck veins, muffled heart sounds) following penetrating chest trauma to the cardiac box is diagnostic of cardiac tamponade. In the haemodynamically unstable patient, immediate pericardiocentesis (needle aspiration of the pericardial sac, subxiphoid approach) is a temporising life-saving measure; if unsuccessful or if the patient arrests, a resuscitative thoracotomy is performed. Definitive repair requires median sternotomy in the operating theatre but should be performed after initial stabilisation. Waiting for echo or CT in a haemodynamically unstable patient with clinical tamponade is inappropriate and dangerous.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.