A 32-year-old man is stabbed in the left 4th intercostal space just lateral to the sternum. On arrival he is anxious, BP 78/50 mmHg, HR 132/min, JVP raised with distended neck veins, heart sounds faint, and bilateral breath sounds are present. Chest X-ray shows no haemopneumothorax. The most appropriate immediate next step is:
- A Pericardiocentesis via the subxiphoid route ✓
- B Urgent CT chest with contrast
- C Insert a left intercostal drain
- D Rapid sequence intubation and ventilation
Correct answer: A. Pericardiocentesis via the subxiphoid route
Explanation
The picture of hypotension, raised JVP and muffled heart sounds with clear lung fields indicates cardiac tamponade from a precordial stab. Pericardiocentesis, ideally via the subxiphoid approach, temporarily relieves the tamponade and can be diagnostic and therapeutic while preparing for definitive thoracotomy or sternotomy. C chest drain addresses pneumothorax or haemothorax, but breath sounds are normal here. CT delays care in an unstable patient, and intubation does not relieve the pericardial pressure.
Reference: ATLS Student Course Manual, American College of Surgeons, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.