# Situation: The emergency department receives three adults injured in a collision between a passenger van and a truck. Each is seen by a separate team, and the nurse is assigned to monitor all three. The second client has a stab wound of the left anterior chest. Blood pressure is 80/64 mmHg, heart rate 128/min, neck veins are distended, heart sounds are muffled, and breath sounds are equal on both sides. Which procedure should the nurse prepare for?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: The emergency department receives three adults injured in a collision between a passenger van and a truck. Each is seen by a separate team, and the nurse is assigned to monitor all three.

The second client has a stab wound of the left anterior chest. Blood pressure is 80/64 mmHg, heart rate 128/min, neck veins are distended, heart sounds are muffled, and breath sounds are equal on both sides. Which procedure should the nurse prepare for?

## 보기

1. Chest tube insertion
2. Central venous catheter insertion
3. Pericardiocentesis **✔ 정답**
4. Endotracheal intubation

**정답: 3**

## 해설

Hypotension, distended neck veins, and muffled heart sounds form Beck's triad of cardiac tamponade. Pericardiocentesis relieves the pressure on the heart as a bridge to surgical repair.

## 심화 해설

Core clinical picture

The combination of hypotension (80/64 mmHg), distended neck veins, and muffled heart sounds is Beck’s triad, the classic bedside signature of cardiac tamponade. In a trauma patient with a left anterior chest stab wound, blood accumulates within the pericardial sac, raising intrapericardial pressure until the right side of the heart cannot fill during diastole. Stroke volume falls, producing tachycardia (128/min) and hypotension. Equal breath sounds make tension pneumothorax less likely, while the muffled heart sounds point toward pericardial fluid rather than a primary airway or pleural problem [1][2].

The priority intervention is pericardiocentesis, which removes pericardial fluid and immediately reduces pressure on the heart, serving as a bridge to definitive surgical repair. In the emergency setting, ultrasound-guided pericardiocentesis is preferred because it improves accuracy and reduces complications [2][3].

Why the other options are not the first priority

| Option | Rationale |
| --- | --- |
| 1. Chest tube insertion | Used for pneumothorax or hemothorax. Breath sounds are equal, and the clinical triad points to pericardial compression, not pleural space pathology. |
| 2. Central venous catheter insertion | May be needed for hemodynamic support, but it does not relieve the mechanical compression on the heart. In tamponade, venous return is already impaired, so volume or central access alone is insufficient. |
| 4. Endotracheal intubation | Indicated for airway compromise or respiratory failure. Positive-pressure ventilation can further reduce venous return and worsen tamponade, so it is not the first-line procedure here. |

Pathophysiology and bedside recognition

Pericardial tamponade occurs when fluid—blood in penetrating trauma—accumulates faster than the pericardium can stretch. The resulting rise in intrapericardial pressure compresses the right atrium and right ventricle, impairing diastolic filling. Because the right ventricle collapses during diastole, left ventricular preload drops, and cardiac output falls [1].

Beck’s triad is specific but may not all appear in every patient; hypotension can be a late sign, and tachycardia is often the earliest compensatory response. Additional clues include pulsus paradoxus, low-voltage QRS, and electrical alternans on ECG. On bedside ultrasound, key findings are pericardial effusion and right ventricular diastolic collapse .

Emergency nursing priorities

The nurse should prepare for ultrasound-guided pericardiocentesis using a subxiphoid approach in most trauma cases, because it offers a direct path to the pericardial space while minimizing injury to surrounding structures [2]. Continuous cardiac monitoring, large-bore IV access, and readiness for rapid deterioration are essential. If pericardiocentesis is unsuccessful or the patient deteriorates, emergent thoracotomy may be required for definitive control of the bleeding source [1][3].

Key point! In penetrating chest trauma with Beck’s triad, do not delay pericardiocentesis for imaging confirmation if the patient is unstable. Bedside ultrasound can confirm the diagnosis rapidly, but clinical recognition alone is enough to justify immediate decompression [2][3].

Watch out! Positive-pressure ventilation can abruptly worsen tamponade by reducing venous return. If intubation is required, be prepared for immediate pericardiocentesis and hemodynamic collapse [1].References (research sources)

- [1]Pericardial tamponade: A comprehensive emergency medicine and echocardiography review.Research articleAlerhand S, Adrian RJ, Long B, Avila J (2022) · DOI: 10.1016/j.ajem.2022.05.001

- [2]Rescuing the heart from tamponade with emergent ultrasound-guided pericardiocentesis: A case report.Case reportIkpeze S, Bondar O, Onyia NK, Perez DV, Mmuotoo JI, Edmond CFG. (2025) · DOI: 10.1016/j.ijscr.2025.111618

- [3]Cardiogenic Versus Obstructive Shock as a Consequence of Road Traffic Accidents: A Case Report on Approach.Case reportSgery ASH, Essa PF, Sultan DL, Sharif AM, Mohammed AI. (2026) · DOI: 10.1155/cric/9592779

## 임상 시나리오

Cardiac Tamponade in Penetrating Chest TraumaRecognizing Beck's Triad and Acting Fast
A patient with a left anterior chest stab wound who presents with hypotension, distended neck veins, and muffled heart sounds has Beck's triad—the hallmark of cardiac tamponade. Equal breath sounds make tension pneumothorax unlikely.

Prepare immediately for ultrasound-guided pericardiocentesis. This removes pericardial blood, reduces pressure on the heart, and restores cardiac output as a bridge to definitive surgical repair.

Monitor vital signs every 5 minutes. Tachycardia above 120/min and systolic BP below 90 mmHg indicate worsening tamponade physiology and the need for rapid intervention.

CautionDo not delay pericardiocentesis for central line placement or intubation. Positive pressure ventilation can further reduce venous return and precipitate cardiovascular collapse in tamponade.

## 핵심 개념

- **Beck's triad** — Classic signs of cardiac tamponade: hypotension, distended neck veins, and muffled heart sounds.
- **Cardiac tamponade** — Compression of the heart by fluid accumulation in the pericardial sac, impairing diastolic filling and reducing cardiac output.
- **Pericardiocentesis** — Emergency procedure to aspirate fluid from the pericardial sac, relieving pressure on the heart as a bridge to surgical repair.
- **Pulsus paradoxus** — An exaggerated drop in systolic blood pressure during inspiration, often seen in cardiac tamponade.
- **Hemopericardium** — Blood accumulation within the pericardial sac, commonly from penetrating chest trauma.

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